1595 
‘‘(VI) The standards must have 
been consistently enforced through ap-
propriate disciplinary mechanisms, in-
cluding, as appropriate, discipline of 
individuals responsible for the failure 
to detect an offense. 
‘‘(VII) After an offense has been 
detected, the organization must have 
taken all reasonable steps to respond 
appropriately to the offense and to 
prevent further similar offenses, in-
cluding repayment of any funds to 
which it was not entitled and any nec-
essary modification to its program to 
prevent and detect criminal, civil, and 
administrative violations under this 
Act. 
‘‘(VIII) The organization must 
periodically undertake reassessment of 
its compliance program to identify 
changes necessary to reflect changes 
within the organization and its facili-
ties. 
‘‘(v) COORDINATION.—The provisions 
of this subparagraph shall apply with re-
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spect to a skilled nursing facility in lieu of 
section 1874(d).’’. 
(2) NURSING FACILITIES.—Section 1919(d)(1) 
of the Social Security Act (42 U.S.C. 1396r(d)(1)), 
as amended by section 1411(c)(2), is amended by 
adding at the end the following new subparagraph: 
‘‘(C) COMPLIANCE
AND
ETHICS
PRO-
GRAM.— 
‘‘(i) REQUIREMENT.—On or after the 
date that is 36 months after the date of 
the enactment of this subparagraph, a 
nursing facility shall, with respect to the 
entity that operates the facility (in this 
subparagraph referred to as the ‘operating 
organization’ or ‘organization’), have in op-
eration a compliance and ethics program 
that is effective in preventing and detect-
ing criminal, civil, and administrative viola-
tions under this Act and in promoting 
quality of care consistent with regulations 
developed under clause (ii). 
‘‘(ii) 
DEVELOPMENT
OF
REGULA-
TIONS.— 
‘‘(I) IN
GENERAL.—Not later 
than the date that is 2 years after 
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such date of the enactment, the Sec-
retary, in consultation with the In-
spector General of the Department of 
Health and Human Services, shall de-
velop regulations for an effective com-
pliance and ethics program for oper-
ating organizations, which may in-
clude a model compliance program. 
‘‘(II) 
DESIGN
OF
REGULA-
TIONS.—Such regulations with respect 
to specific elements or formality of a 
program may vary with the size of the 
organization, such that larger organi-
zations should have a more formal 
and rigorous program and include es-
tablished written policies defining the 
standards and procedures to be fol-
lowed by its employees. Such require-
ments may specifically apply to the 
corporate level management of multi- 
unit nursing home chains. 
‘‘(III) EVALUATION.—Not later 
than 3 years after the date of promul-
gation of regulations under this clause 
the Secretary shall complete an eval-
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uation of the compliance and ethics 
programs required to be established 
under this subparagraph. Such eval-
uation shall determine if such pro-
grams led to changes in deficiency ci-
tations, changes in quality perform-
ance, or changes in other metrics of 
resident quality of care. The Secretary 
shall submit to Congress a report on 
such evaluation and shall include in 
such report such recommendations re-
garding changes in the requirements 
for such programs as the Secretary 
determines appropriate. 
‘‘(iii) REQUIREMENTS
FOR
COMPLI-
ANCE
AND
ETHICS
PROGRAMS.—In this 
subparagraph, the term ‘compliance and 
ethics program’ means, with respect to a 
nursing facility, a program of the oper-
ating organization that— 
‘‘(I) has been reasonably de-
signed, implemented, and enforced so 
that it generally will be effective in 
preventing and detecting criminal, 
civil, and administrative violations 
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under this Act and in promoting qual-
ity of care; and 
‘‘(II) includes at least the re-
quired components specified in clause 
(iv). 
‘‘(iv) REQUIRED
COMPONENTS
OF 
PROGRAM.—The required components of a 
compliance and ethics program of an orga-
nization are the following: 
‘‘(I) The organization must have 
established compliance standards and 
procedures to be followed by its em-
ployees and other agents that are rea-
sonably capable of reducing the pros-
pect of criminal, civil, and administra-
tive violations under this Act. 
‘‘(II) Specific individuals within 
high-level personnel of the organiza-
tion must have been assigned overall 
responsibility to oversee compliance 
with such standards and procedures 
and has sufficient resources and au-
thority to assure such compliance. 
‘‘(III) The organization must 
have used due care not to delegate 
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substantial discretionary authority to 
individuals whom the organization 
knew, or should have known through 
the exercise of due diligence, had a 
propensity to engage in criminal, civil, 
and administrative violations under 
this Act. 
‘‘(IV) The organization must 
have taken steps to communicate ef-
fectively its standards and procedures 
to all employees and other agents, 
such as by requiring participation in 
training programs or by disseminating 
publications that explain in a practical 
manner what is required. 
‘‘(V) The organization must have 
taken reasonable steps to achieve com-
pliance with its standards, such as by 
utilizing monitoring and auditing sys-
tems reasonably designed to detect 
criminal, civil, and administrative vio-
lations under this Act by its employ-
ees and other agents and by having in 
place and publicizing a reporting sys-
tem whereby employees and other 
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agents could report violations by oth-
ers within the organization without 
fear of retribution. 
‘‘(VI) The standards must have 
been consistently enforced through ap-
propriate disciplinary mechanisms, in-
cluding, as appropriate, discipline of 
individuals responsible for the failure 
to detect an offense. 
‘‘(VII) After an offense has been 
detected, the organization must have 
taken all reasonable steps to respond 
appropriately to the offense and to 
prevent further similar offenses, in-
cluding repayment of any funds to 
which it was not entitled and any nec-
essary modification to its program to 
prevent and detect criminal, civil, and 
administrative violations under this 
Act. 
‘‘(VIII) The organization must 
periodically undertake reassessment of 
its compliance program to identify 
changes necessary to reflect changes 
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within the organization and its facili-
ties. 
‘‘(v) COORDINATION.—The provisions 
of this subparagraph shall apply with re-
spect to a nursing facility in lieu of section 
1902(a)(77).’’. 
(b) QUALITY ASSURANCE AND PERFORMANCE IM-
PROVEMENT PROGRAM.— 
(1) SKILLED
NURSING
FACILITIES.—Section 
1819(b)(1)(B) of the Social Security Act (42 U.S.C. 
1396r(b)(1)(B)) is amended— 
(A) by striking ‘‘ASSURANCE’’ and insert-
ing ‘‘ASSURANCE
AND
QUALITY
ASSURANCE 
AND PERFORMANCE IMPROVEMENT PROGRAM’’; 
(B) by designating the matter beginning 
with ‘‘A nursing facility’’ as a clause (i) with 
the heading ‘‘IN GENERAL.—’’ and the appro-
priate indentation; and 
(C) by adding at the end the following new 
clause: 
‘‘(ii) QUALITY ASSURANCE AND PER-
FORMANCE IMPROVEMENT PROGRAM.— 
‘‘(I) IN
GENERAL.—Not later 
than December 31, 2011, the Sec-
retary shall establish and implement a 
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quality assurance and performance 
improvement program (in this clause 
referred to as the ‘QAPI program’) 
for skilled nursing facilities, including 
multi-unit chains of such facilities. 
Under the QAPI program, the Sec-
retary shall establish standards relat-
ing to such facilities and provide tech-
nical assistance to such facilities on 
the development of best practices in 
order to meet such standards. Not 
later than 1 year after the date on 
which the regulations are promulgated 
under subclause (II), a skilled nursing 
facility must submit to the Secretary 
a plan for the facility to meet such 
standards and implement such best 
practices, including how to coordinate 
the implementation of such plan with 
quality assessment and assurance ac-
tivities conducted under clause (i). 
‘‘(II) REGULATIONS.—The Sec-
retary shall promulgate regulations to 
carry out this clause.’’. 
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(2) 
NURSING
FACILITIES.—Section 
1919(b)(1)(B) of the Social Security Act (42 U.S.C. 
1396r(b)(1)(B)) is amended— 
(A) by striking ‘‘ASSURANCE’’ and insert-
ing ‘‘ASSURANCE
AND
QUALITY
ASSURANCE 
AND PERFORMANCE IMPROVEMENT PROGRAM’’; 
(B) by designating the matter beginning 
with ‘‘A nursing facility’’ as a clause (i) with 
the heading ‘‘IN GENERAL.—’’ and the appro-
priate indentation; and 
(C) by adding at the end the following new 
clause: 
‘‘(ii) QUALITY ASSURANCE AND PER-
FORMANCE IMPROVEMENT PROGRAM.— 
‘‘(I) IN
GENERAL.—Not later 
than December 31, 2011, the Sec-
retary shall establish and implement a 
quality assurance and performance 
improvement program (in this clause 
referred to as the ‘QAPI program’) 
for nursing facilities, including multi- 
unit chains of such facilities. Under 
the QAPI program, the Secretary 
shall establish standards relating to 
such facilities and provide technical 
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assistance to such facilities on the de-
velopment of best practices in order to 
meet such standards. Not later than 1 
year after the date on which the regu-
lations are promulgated under sub-
clause (II), a nursing facility must 
submit to the Secretary a plan for the 
facility to meet such standards and 
implement such best practices, includ-
ing how to coordinate the implementa-
tion of such plan with quality assess-
ment and assurance activities con-
ducted under clause (i). 
‘‘(II) REGULATIONS.—The Sec-
retary shall promulgate regulations to 
carry out this clause.’’. 
(3) PROPOSAL TO REVISE QUALITY ASSURANCE 
AND
PERFORMANCE
IMPROVEMENT
PROGRAMS.— 
The Secretary shall include in the proposed rule 
published under section 1888(e) of the Social Secu-
rity Act (42 U.S.C. 1395yy(e)(5)(A)) for the subse-
quent fiscal year to the extent otherwise authorized 
under section 1819(b)(1)(B) or 1819(d)(1)(C) of the 
Social Security Act or other statutory or regulatory 
authority, one or more proposals for skilled nursing 
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facilities to modify and strengthen quality assurance 
and performance improvement programs in such fa-
cilities. At the time of publication of such proposed 
rule and to the extent otherwise authorized under 
section 1919(b)(1)(B) or 1919(d)(1)(C) of such Act 
or other regulatory authority. 
(4) FACILITY
PLAN.—Not later than 1 year 
after the date on which the regulations are promul-
gated under subclause (II) of clause (ii) of sections 
1819(b)(1)(B) and 1919(b)(1)(B) of the Social Se-
curity Act, as added by paragraphs (1) and (2), a 
skilled nursing facility and a nursing facility must 
submit to the Secretary a plan for the facility to 
meet the standards under such regulations and im-
plement such best practices, including how to coordi-
nate the implementation of such plan with quality 
assessment and assurance activities conducted under 
clause (i) of such sections. 
(c) GAO STUDY
ON NURSING FACILITY UNDER-
CAPITALIZATION.— 
(1) IN GENERAL.—The Comptroller General of 
the United States shall conduct a study that exam-
ines the following: 
(A) The extent to which corporations that 
own or operate large numbers of nursing facili-
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ties, taking into account ownership type (includ-
ing private equity and control interests), are 
undercapitalizing such facilities. 
(B) The effects of such undercapitalization 
on quality of care, including staffing and food 
costs, at such facilities. 
(C) Options to address such undercapital-
ization, such as requirements relating to surety 
bonds, liability insurance, or minimum capital-
ization. 
(2) REPORT.—Not later than 18 months after 
the date of the enactment of this Act, the Comp-
troller General shall submit to Congress a report on 
the study conducted under paragraph (1). 
(3) NURSING FACILITY.—In this subsection, the 
term ‘‘nursing facility’’ includes a skilled nursing fa-
cility. 
SEC. 1413. NURSING HOME COMPARE MEDICARE WEBSITE. 
(a) SKILLED NURSING FACILITIES.— 
(1) IN GENERAL.—Section 1819 of the Social 
Security Act (42 U.S.C. 1395i–3) is amended— 
(A) by redesignating subsection (i) as sub-
section (j); and 
(B) by inserting after subsection (h) the 
following new subsection: 
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‘‘(i) NURSING HOME COMPARE WEBSITE.— 
‘‘(1) INCLUSION
OF
ADDITIONAL
INFORMA-
TION.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
ensure that the Department of Health and 
Human Services includes, as part of the infor-
mation provided for comparison of nursing 
homes on the official Internet website of the 
Federal Government for Medicare beneficiaries 
(commonly referred to as the ‘Nursing Home 
Compare’ Medicare website) (or a successor 
website), the following information in a manner 
that is prominent, easily accessible, readily un-
derstandable to consumers of long-term care 
services, and searchable: 
‘‘(i) Information that is reported to 
the Secretary under section 1124(c)(4). 
‘‘(ii) Information on the ‘Special 
Focus Facility program’ (or a successor 
program) established by the Centers for 
Medicare and Medicaid Services, according 
to procedures established by the Secretary. 
Such procedures shall provide for the in-
clusion of information with respect to, and 
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the names and locations of, those facilities 
that, since the previous quarter— 
‘‘(I) were newly enrolled in the 
program; 
‘‘(II) are enrolled in the program 
and have failed to significantly im-
prove; 
‘‘(III) are enrolled in the pro-
gram and have significantly improved; 
‘‘(IV) have graduated from the 
program; and 
‘‘(V) have closed voluntarily or 
no longer participate under this title. 
‘‘(iii) Staffing data for each facility 
(including resident census data and data 
on the hours of care provided per resident 
per day) based on data submitted under 
subsection (b)(8)(C), including information 
on staffing turnover and tenure, in a for-
mat that is clearly understandable to con-
sumers of long-term care services and al-
lows such consumers to compare dif-
ferences in staffing between facilities and 
State and national averages for the facili-
ties. Such format shall include— 
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‘‘(I) concise explanations of how 
to interpret the data (such as a plain 
English explanation of data reflecting 
‘nursing home staff hours per resident 
day’); 
‘‘(II) differences in types of staff 
(such as training associated with dif-
ferent categories of staff); 
‘‘(III) the relationship between 
nurse staffing levels and quality of 
care; and 
‘‘(IV) an explanation that appro-
priate staffing levels vary based on 
patient case mix. 
‘‘(iv) Links to State Internet websites 
with information regarding State survey 
and certification programs, links to Form 
2567 State inspection reports (or a suc-
cessor form) on such websites, information 
to guide consumers in how to interpret and 
understand such reports, and the facility 
plan of correction or other response to 
such report. 
‘‘(v) The standardized complaint form 
developed under subsection (f)(8), includ-
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ing explanatory material on what com-
plaint forms are, how they are used, and 
how to file a complaint with the State sur-
vey and certification program and the 
State long-term care ombudsman program. 
‘‘(vi) Summary information on the 
number, type, severity, and outcome of 
substantiated complaints. 
‘‘(vii) The number of adjudicated in-
stances of criminal violations by employees 
of a nursing facility— 
‘‘(I) that were committed inside 
the facility; 
‘‘(II) with respect to such in-
stances of violations or crimes com-
mitted inside of the facility that were 
the violations or crimes of abuse, ne-
glect, and exploitation, criminal sexual 
abuse, or other violations or crimes 
that resulted in serious bodily injury; 
and 
‘‘(III) the number of civil mone-
tary penalties levied against the facil-
ity, employees, contractors, and other 
agents. 
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‘‘(B) DEADLINE FOR PROVISION OF INFOR-
MATION.— 
‘‘(i) IN
GENERAL.—Except as pro-
vided in clause (ii), the Secretary shall en-
sure that the information described in sub-
paragraph (A) is included on such website 
(or a successor website) not later than 1 
year after the date of the enactment of this 
subsection. 
‘‘(ii) 
EXCEPTION.—The 
Secretary 
shall ensure that the information described 
in subparagraph (A)(i) and (A)(iii) is in-
cluded on such website (or a successor 
website) not later than the date on which 
the requirements under section 1124(c)(4) 
and subsection (b)(8)(C)(ii) are imple-
mented. 
‘‘(2) 
REVIEW
AND
MODIFICATION
OF 
WEBSITE.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
establish a process— 
‘‘(i) to review the accuracy, clarity of 
presentation, timeliness, and comprehen-
siveness of information reported on such 
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website as of the day before the date of the 
enactment of this subsection; and 
‘‘(ii) not later than 1 year after the 
date of the enactment of this subsection, to 
modify or revamp such website in accord-
ance with the review conducted under 
clause (i). 
‘‘(B) CONSULTATION.—In conducting the 
review under subparagraph (A)(i), the Sec-
retary shall consult with— 
‘‘(i) State long-term care ombudsman 
programs; 
‘‘(ii) consumer advocacy groups; 
‘‘(iii) provider stakeholder groups; and 
‘‘(iv) any other representatives of pro-
grams or groups the Secretary determines 
appropriate.’’. 
(2) TIMELINESS
OF
SUBMISSION
OF
SURVEY 
AND CERTIFICATION INFORMATION.— 
(A) IN GENERAL.—Section 1819(g)(5) of 
the Social Security Act (42 U.S.C. 1395i– 
3(g)(5)) is amended by adding at the end the 
following new subparagraph: 
‘‘(E) SUBMISSION OF SURVEY AND CER-
TIFICATION
INFORMATION
TO
THE
SEC-
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RETARY.—In order to improve the timeliness of 
information made available to the public under 
subparagraph (A) and provided on the Nursing 
Home Compare Medicare website under sub-
section (i), each State shall submit information 
respecting any survey or certification made re-
specting a skilled nursing facility (including any 
enforcement actions taken by the State) to the 
Secretary not later than the date on which the 
State sends such information to the facility. 
The Secretary shall use the information sub-
mitted under the preceding sentence to update 
the information provided on the Nursing Home 
Compare Medicare website as expeditiously as 
practicable but not less frequently than quar-
terly.’’. 
(B) EFFECTIVE
DATE.—The amendment 
made by this paragraph shall take effect 1 year 
after the date of the enactment of this Act. 
(3) SPECIAL FOCUS FACILITY PROGRAM.—Sec-
tion 1819(f) of such Act is amended by adding at 
the end the following new paragraph: 
‘‘(8) SPECIAL FOCUS FACILITY PROGRAM.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
conduct a special focus facility program for en-
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forcement of requirements for skilled nursing 
facilities that the Secretary has identified as 
having substantially failed to meet applicable 
requirement of this Act. 
‘‘(B) PERIODIC
SURVEYS.—Under such 
program the Secretary shall conduct surveys of 
each facility in the program not less than once 
every 6 months.’’. 
(b) NURSING FACILITIES.— 
(1) IN GENERAL.—Section 1919 of the Social 
Security Act (42 U.S.C. 1396r) is amended— 
(A) by redesignating subsection (i) as sub-
section (j); and 
(B) by inserting after subsection (h) the 
following new subsection: 
‘‘(i) NURSING HOME COMPARE WEBSITE.— 
‘‘(1) INCLUSION
OF
ADDITIONAL
INFORMA-
TION.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
ensure that the Department of Health and 
Human Services includes, as part of the infor-
mation provided for comparison of nursing 
homes on the official Internet website of the 
Federal Government for Medicare beneficiaries 
(commonly referred to as the ‘Nursing Home 
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Compare’ Medicare website) (or a successor 
website), the following information in a manner 
that is prominent, easily accessible, readily un-
derstandable to consumers of long-term care 
services, and searchable: 
‘‘(i) Staffing data for each facility (in-
cluding resident census data and data on 
the hours of care provided per resident per 
day) based on data submitted under sub-
section (b)(8)(C)(ii), including information 
on staffing turnover and tenure, in a for-
mat that is clearly understandable to con-
sumers of long-term care services and al-
lows such consumers to compare dif-
ferences in staffing between facilities and 
State and national averages for the facili-
ties. Such format shall include— 
‘‘(I) concise explanations of how 
to interpret the data (such as plain 
English explanation of data reflecting 
‘nursing home staff hours per resident 
day’); 
‘‘(II) differences in types of staff 
(such as training associated with dif-
ferent categories of staff); 
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‘‘(III) the relationship between 
nurse staffing levels and quality of 
care; and 
‘‘(IV) an explanation that appro-
priate staffing levels vary based on 
patient case mix. 
‘‘(ii) Links to State Internet websites 
with information regarding State survey 
and certification programs, links to Form 
2567 State inspection reports (or a suc-
cessor form) on such websites, information 
to guide consumers in how to interpret and 
understand such reports, and the facility 
plan of correction or other response to 
such report. 
‘‘(iii) The standardized complaint 
form developed under subsection (f)(10), 
including explanatory material on what 
complaint forms are, how they are used, 
and how to file a complaint with the State 
survey and certification program and the 
State long-term care ombudsman program. 
‘‘(iv) Summary information on the 
number, type, severity, and outcome of 
substantiated complaints. 
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‘‘(v) The number of adjudicated in-
stances of criminal violations by employees 
of a nursing facility— 
‘‘(I) that were committed inside 
of the facility; and 
‘‘(II) with respect to such in-
stances of violations or crimes com-
mitted outside of the facility, that 
were the violations or crimes that re-
sulted in the serious bodily injury of 
an elder. 
‘‘(B) DEADLINE FOR PROVISION OF INFOR-
MATION.— 
‘‘(i) IN
GENERAL.—Except as pro-
vided in clause (ii), the Secretary shall en-
sure that the information described in sub-
paragraph (A) is included on such website 
(or a successor website) not later than 1 
year after the date of the enactment of this 
subsection. 
‘‘(ii) 
EXCEPTION.—The 
Secretary 
shall ensure that the information described 
in subparagraph (A)(i) and (A)(iii) is in-
cluded on such website (or a successor 
website) not later than the date on which 
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the requirements under section 1124(c)(4) 
and subsection (b)(8)(C)(ii) are imple-
mented. 
‘‘(2) 
REVIEW
AND
MODIFICATION
OF 
WEBSITE.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
establish a process— 
‘‘(i) to review the accuracy, clarity of 
presentation, timeliness, and comprehen-
siveness of information reported on such 
website as of the day before the date of the 
enactment of this subsection; and 
‘‘(ii) not later than 1 year after the 
date of the enactment of this subsection, to 
modify or revamp such website in accord-
ance with the review conducted under 
clause (i). 
‘‘(B) CONSULTATION.—In conducting the 
review under subparagraph (A)(i), the Sec-
retary shall consult with— 
‘‘(i) State long-term care ombudsman 
programs; 
‘‘(ii) consumer advocacy groups; 
‘‘(iii) provider stakeholder groups; 
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‘‘(iv) skilled nursing facility employees 
and their representatives; and 
‘‘(v) any other representatives of pro-
grams or groups the Secretary determines 
appropriate.’’. 
(2) TIMELINESS
OF
SUBMISSION
OF
SURVEY 
AND CERTIFICATION INFORMATION.— 
(A) IN GENERAL.—Section 1919(g)(5) of 
the Social Security Act (42 U.S.C. 1396r(g)(5)) 
is amended by adding at the end the following 
new subparagraph: 
‘‘(E) SUBMISSION OF SURVEY AND CER-
TIFICATION
INFORMATION
TO
THE
SEC-
RETARY.—In order to improve the timeliness of 
information made available to the public under 
subparagraph (A) and provided on the Nursing 
Home Compare Medicare website under sub-
section (i), each State shall submit information 
respecting any survey or certification made re-
specting a nursing facility (including any en-
forcement actions taken by the State) to the 
Secretary not later than the date on which the 
State sends such information to the facility. 
The Secretary shall use the information sub-
mitted under the preceding sentence to update 
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the information provided on the Nursing Home 
Compare Medicare website as expeditiously as 
practicable but not less frequently than quar-
terly.’’. 
(B) EFFECTIVE
DATE.—The amendment 
made by this paragraph shall take effect 1 year 
after the date of the enactment of this Act. 
(3) SPECIAL FOCUS FACILITY PROGRAM.—Sec-
tion 1919(f) of such Act is amended by adding at 
the end of the following new paragraph: 
‘‘(10) SPECIAL FOCUS FACILITY PROGRAM.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
conduct a special focus facility program for en-
forcement of requirements for nursing facilities 
that the Secretary has identified as having sub-
stantially failed to meet applicable requirements 
of this Act. 
‘‘(B) PERIODIC
SURVEYS.—Under such 
program the Secretary shall conduct surveys of 
each facility in the program not less often than 
once every 6 months.’’. 
(c) AVAILABILITY OF REPORTS ON SURVEYS, CER-
TIFICATIONS, AND COMPLAINT INVESTIGATIONS.— 
(1) SKILLED
NURSING
FACILITIES.—Section 
1819(d)(1) of the Social Security Act (42 U.S.C. 
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1395i–3(d)(1)), as amended by sections 1411 and 
1412, is amended by adding at the end the following 
new subparagraph: 
‘‘(D) AVAILABILITY OF SURVEY, CERTIFI-
CATION, AND COMPLAINT INVESTIGATION RE-
PORTS.—A skilled nursing facility must— 
‘‘(i) have reports with respect to any 
surveys, certifications, and complaint in-
vestigations made respecting the facility 
during the 3 preceding years available for 
any individual to review upon request; and 
‘‘(ii) post notice of the availability of 
such reports in areas of the facility that 
are prominent and accessible to the public. 
The facility shall not make available under 
clause (i) identifying information about com-
plainants or residents.’’. 
(2) NURSING FACILITIES.—Section 1919(d)(1) 
of the Social Security Act (42 U.S.C. 1396r(d)(1)), 
as amended by sections 1411 and 1412, is amended 
by adding at the end the following new subpara-
graph: 
‘‘(D) AVAILABILITY OF SURVEY, CERTIFI-
CATION, AND COMPLAINT INVESTIGATION RE-
PORTS.—A nursing facility must— 
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‘‘(i) have reports with respect to any 
surveys, certifications, and complaint in-
vestigations made respecting the facility 
during the 3 preceding years available for 
any individual to review upon request; and 
‘‘(ii) post notice of the availability of 
such reports in areas of the facility that 
are prominent and accessible to the public. 
The facility shall not make available under 
clause (i) identifying information about com-
plainants or residents.’’. 
(3) EFFECTIVE DATE.—The amendments made 
by this subsection shall take effect 1 year after the 
date of the enactment of this Act. 
(d) GUIDANCE TO STATES ON FORM 2567 STATE IN-
SPECTION REPORTS AND COMPLAINT INVESTIGATION RE-
PORTS.— 
(1) GUIDANCE.—The Secretary of Health and 
Human Services (in this subtitle referred to as the 
‘‘Secretary’’) shall provide guidance to States on 
how States can establish electronic links to Form 
2567 State inspection reports (or a successor form), 
complaint investigation reports, and a facility’s plan 
of correction or other response to such Form 2567 
State inspection reports (or a successor form) on the 
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Internet website of the State that provides informa-
tion on skilled nursing facilities and nursing facili-
ties and the Secretary shall, if possible, include such 
information on Nursing Home Compare. 
(2) REQUIREMENT.—Section 1902(a)(9) of the 
Social Security Act (42 U.S.C. 1396a(a)(9)) is 
amended— 
(A) by striking ‘‘and’’ at the end of sub-
paragraph (B); 
(B) by striking the semicolon at the end of 
subparagraph (C) and inserting ‘‘, and’’; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(D) that the State maintain a consumer- 
oriented website providing useful information to 
consumers regarding all skilled nursing facili-
ties and all nursing facilities in the State, in-
cluding for each facility, Form 2567 State in-
spection reports (or a successor form), com-
plaint investigation reports, the facility’s plan of 
correction, and such other information that the 
State or the Secretary considers useful in as-
sisting the public to assess the quality of long 
term care options and the quality of care pro-
vided by individual facilities;’’. 
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(3) DEFINITIONS.—In this subsection: 
(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. 1395i–3(a)). 
SEC. 1414. REPORTING OF EXPENDITURES. 
Section 1888 of the Social Security Act (42 U.S.C. 
1395yy) is amended by adding at the end the following 
new subsection: 
‘‘(f) REPORTING
OF
DIRECT
CARE
EXPENDI-
TURES.— 
‘‘(1) IN GENERAL.—For cost reports submitted 
under this title for cost reporting periods beginning 
on or after the date that is 3 years after the date 
of the enactment of this subsection, skilled nursing 
facilities shall separately report expenditures for 
wages and benefits for direct care staff (breaking 
out (at a minimum) registered nurses, licensed pro-
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fessional nurses, certified nurse assistants, and other 
medical and therapy staff). 
‘‘(2) MODIFICATION OF FORM.—The Secretary, 
in consultation with private sector accountants expe-
rienced with skilled nursing facility cost reports, 
shall redesign such reports to meet the requirement 
of paragraph (1) not later than 1 year after the date 
of the enactment of this subsection. 
‘‘(3) CATEGORIZATION
BY
FUNCTIONAL
AC-
COUNTS.—Not later than 30 months after the date 
of the enactment of this subsection, the Secretary, 
working in consultation with the Medicare Payment 
Advisory Commission, the Inspector General of the 
Department of Health and Human Services, and 
other expert parties the Secretary determines appro-
priate, shall take the expenditures listed on cost re-
ports, as modified under paragraph (1), submitted 
by skilled nursing facilities and categorize such ex-
penditures, regardless of any source of payment for 
such expenditures, for each skilled nursing facility 
into the following functional accounts on an annual 
basis: 
‘‘(A) Spending on direct care services (in-
cluding nursing, therapy, and medical services). 
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‘‘(B) Spending on indirect care (including 
housekeeping and dietary services). 
‘‘(C) Capital assets (including building and 
land costs). 
‘‘(D) Administrative services costs. 
‘‘(4) AVAILABILITY
OF
INFORMATION
SUB-
MITTED.—The Secretary shall establish procedures 
to make information on expenditures submitted 
under this subsection readily available to interested 
parties upon request, subject to such requirements 
as the Secretary may specify under the procedures 
established under this paragraph.’’. 
SEC. 1415. STANDARDIZED COMPLAINT FORM. 
(a) SKILLED NURSING FACILITIES.— 
(1) DEVELOPMENT BY THE SECRETARY.—Sec-
tion 1819(f) of the Social Security Act (42 U.S.C. 
1395i–3(f)), as amended by section 1413(a)(3), is 
amended by adding at the end the following new 
paragraph: 
‘‘(9) 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- 
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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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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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‘‘(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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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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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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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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1634 
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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‘‘(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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1636 
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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1637 
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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1638 
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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1639 
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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‘‘(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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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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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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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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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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‘‘(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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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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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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1648 
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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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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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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(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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1653 
‘‘(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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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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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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1656 
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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1658 
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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1659 
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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1660 
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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1661 
(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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1662 
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. 
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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‘‘(H) Public and private purchasers of 
health care items and services. 
‘‘(I) Labor organizations. 
‘‘(J) Relevant departments or agencies of 
the United States. 
‘‘(K) Biopharmaceutical companies and 
manufacturers of medical devices. 
‘‘(L) Licensing, credentialing, and accred-
iting bodies. 
‘‘(7) FUNDING.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
provide for the transfer, from the Federal Hos-
pital Insurance Trust Fund under section 1817 
and the Federal Supplementary Medical Insur-
ance Trust Fund under section 1841 (in such 
proportion as the Secretary determines appro-
priate), of $1,000,000, to the Secretary for pur-
poses of carrying out this subsection for each of 
the fiscal years 2010 through 2014. 
‘‘(B) 
AUTHORIZATION
OF
APPROPRIA-
TIONS.—For purposes of carrying out the provi-
sions of this subsection, in addition to funds 
otherwise available, out of any funds in the 
Treasury not otherwise appropriated, there are 
appropriated to the Secretary of Health and 
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Human Services $1,000,000 for each of the fis-
cal years 2010 through 2014.’’. 
SEC. 1444. APPLICATION OF QUALITY MEASURES. 
(a) 
INPATIENT
HOSPITAL
SERVICES.—Section 
1886(b)(3)(B) of such Act (42 U.S.C. 1395ww(b)(3)(B)) 
is amended by adding at the end the following new clause: 
‘‘(x)(I) Subject to subclause (II), for purposes of re-
porting data on quality measures for inpatient hospital 
services furnished during fiscal year 2012 and each subse-
quent fiscal year, the quality measures specified under 
clause (viii) shall be measures selected by the Secretary 
from measures that have been endorsed by the entity with 
a contract with the Secretary under section 1890(a). 
‘‘(II) In the case of a specified area or medical topic 
determined appropriate by the Secretary for which a fea-
sible and practical quality measure has not been endorsed 
by the entity with a contract under section 1890(a), the 
Secretary may specify a measure that is not so endorsed 
as long as due consideration is given to measures that 
have been endorsed or adopted by a consensus organiza-
tion identified by the Secretary. The Secretary shall sub-
mit such a non-endorsed measure to the entity for consid-
eration for endorsement. If the entity considers but does 
not endorse such a measure and if the Secretary does not 
phase-out use of such measure, the Secretary shall include 
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the rationale for continued use of such a measure in rule-
making.’’. 
(b) OUTPATIENT
HOSPITAL
SERVICES.—Section 
1833(t)(17) of such Act (42 U.S.C. 1395l(t)(17)) is 
amended by adding at the end the following new subpara-
graph: 
‘‘(F) USE OF ENDORSED QUALITY MEAS-
URES.—The provisions of clause (x) of section 
1886(b)(3)(C) shall apply to quality measures 
for covered OPD services under this paragraph 
in the same manner as such provisions apply to 
quality measures for inpatient hospital serv-
ices.’’. 
(c) 
PHYSICIANS’ 
SERVICES.—Section 
1848(k)(2)(C)(ii) of such Act (42 U.S.C. 1395w– 
4(k)(2)(C)(ii)) is amended by adding at the end the fol-
lowing: ‘‘The Secretary shall submit such a non-endorsed 
measure to the entity for consideration for endorsement. 
If the entity considers but does not endorse such a meas-
ure and if the Secretary does not phase-out use of such 
measure, the Secretary shall include the rationale for con-
tinued use of such a measure in rulemaking.’’. 
(d) 
RENAL
DIALYSIS
SERVICES.—Section 
1881(h)(2)(B)(ii) 
of 
such 
Act 
(42 
U.S.C. 
1395rr(h)(2)(B)(ii)) is amended by adding at the end the 
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following: ‘‘The Secretary shall submit such a non-en-
dorsed measure to the entity for consideration for endorse-
ment. If the entity considers but does not endorse such 
a measure and if the Secretary does not phase-out use 
of such measure, the Secretary shall include the rationale 
for continued use of such a measure in rulemaking.’’. 
(e) 
ENDORSEMENT
OF
STANDARDS.—Section 
1890(b)(2) of the Social Security Act (42 U.S.C. 
1395aaa(b)(2)) is amended by adding after and below sub-
paragraph (B) the following: 
‘‘ ‘If the entity does not endorse a measure, such en-
tity shall explain the reasons and provide sugges-
tions about changes to such measure that might 
make it a potentially endorsable measure.’ ’’. 
(f) EFFECTIVE DATE.—Except as otherwise pro-
vided, the amendments made by this section shall apply 
to quality measures applied for payment years beginning 
with 2012 or fiscal year 2012, as the case may be. 
SEC. 1445. CONSENSUS-BASED ENTITY FUNDING. 
Section 1890(d) of the Social Security Act (42 U.S.C. 
1395aaa(d)) is amended by striking ‘‘for each of fiscal 
years 2009 through 2012’’ and inserting ‘‘for fiscal year 
2009, and $12,000,000 for each of the fiscal years 2010 
through 2012.’’ 
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Subtitle D—Physician Payments 
Sunshine Provision 
SEC. 1451. REPORTS ON FINANCIAL RELATIONSHIPS BE-
TWEEN 
MANUFACTURERS 
AND 
DISTRIBU-
TORS 
OF 
COVERED 
DRUGS, 
DEVICES, 
BIOLOGICALS, 
OR 
MEDICAL 
SUPPLIES 
UNDER MEDICARE, MEDICAID, OR CHIP AND 
PHYSICIANS AND OTHER HEALTH CARE ENTI-
TIES AND BETWEEN PHYSICIANS AND OTHER 
HEALTH CARE ENTITIES. 
(a) IN GENERAL.—Part A of title XI of the Social 
Security Act (42 U.S.C. 1301 et seq.), as amended by sec-
tion 1631(a), is further amended by inserting after section 
1128G the following new section: 
‘‘SEC. 1128H. FINANCIAL REPORTS ON PHYSICIANS’ FINAN-
CIAL RELATIONSHIPS WITH MANUFACTUR-
ERS 
AND 
DISTRIBUTORS 
OF 
COVERED 
DRUGS, DEVICES, BIOLOGICALS, OR MEDICAL 
SUPPLIES UNDER MEDICARE, MEDICAID, OR 
CHIP AND WITH ENTITIES THAT BILL FOR 
SERVICES UNDER MEDICARE. 
‘‘(a) REPORTING OF PAYMENTS OR OTHER TRANS-
FERS OF VALUE.— 
‘‘(1) IN GENERAL.—Except as provided in this 
subsection, not later than March 31, 2011, and an-
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nually thereafter, each applicable manufacturer or 
distributor that provides a payment or other transfer 
of value to a covered recipient, or to an entity or in-
dividual at the request of or designated on behalf of 
a covered recipient, shall submit to the Secretary, in 
such electronic form as the Secretary shall require, 
the following information with respect to the pre-
ceding calendar year: 
‘‘(A) With respect to the covered recipient, 
the recipient’s name, business address, physi-
cian specialty, and national provider identifier. 
‘‘(B) With respect to the payment or other 
transfer of value, other than a drug sample— 
‘‘(i) its value and date; 
‘‘(ii) the name of the related drug, de-
vice, or supply, if available; and 
‘‘(iii) a description of its form, indi-
cated (as appropriate for all that apply) 
as— 
‘‘(I) cash or a cash equivalent; 
‘‘(II) in-kind items or services; 
‘‘(III) stock, a stock option, or 
any other ownership interest, divi-
dend, profit, or other return on invest-
ment; or 
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‘‘(IV) any other form (as defined 
by the Secretary). 
‘‘(C) With respect to a drug sample, the 
name, number, date, and dosage units of the 
sample. 
‘‘(2) 
AGGREGATE
REPORTING.—Information 
submitted by an applicable manufacturer or dis-
tributor under paragraph (1) shall include the ag-
gregate amount of all payments or other transfers of 
value provided by the manufacturer or distributor to 
covered recipients (and to entities or individuals at 
the request of or designated on behalf of a covered 
recipient) during the year involved, including all pay-
ments and transfers of value regardless of whether 
such payments or transfer of value were individually 
disclosed. 
‘‘(3) SPECIAL RULE FOR CERTAIN PAYMENTS 
OR
OTHER
TRANSFERS
OF
VALUE.—In the case 
where an applicable manufacturer or distributor pro-
vides a payment or other transfer of value to an en-
tity or individual at the request of or designated on 
behalf of a covered recipient, the manufacturer or 
distributor shall disclose that payment or other 
transfer of value under the name of the covered re-
cipient. 
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‘‘(4) DELAYED
REPORTING
FOR
PAYMENTS 
MADE
PURSUANT
TO
PRODUCT
DEVELOPMENT 
AGREEMENTS.—In the case of a payment or other 
transfer of value made to a covered recipient by an 
applicable manufacturer or distributor pursuant to a 
product development agreement for services fur-
nished in connection with the development of a new 
drug, device, biological, or medical supply, the appli-
cable manufacturer or distributor may report the 
value and recipient of such payment or other trans-
fer of value in the first reporting period under this 
subsection in the next reporting deadline after the 
earlier of the following: 
‘‘(A) The date of the approval or clearance 
of the covered drug, device, biological, or med-
ical supply by the Food and Drug Administra-
tion. 
‘‘(B) Two calendar years after the date 
such payment or other transfer of value was 
made. 
‘‘(5) DELAYED
REPORTING
FOR
PAYMENTS 
MADE PURSUANT TO CLINICAL INVESTIGATIONS.—In 
the case of a payment or other transfer of value 
made to a covered recipient by an applicable manu-
facturer or distributor in connection with a clinical 
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investigation regarding a new drug, device, biologi-
cal, or medical supply, the applicable manufacturer 
or distributor may report as required under this sec-
tion in the next reporting period under this sub-
section after the earlier of the following: 
‘‘(A) The date that the clinical investiga-
tion is registered on the website maintained by 
the National Institutes of Health pursuant to 
section 671 of the Food and Drug Administra-
tion Amendments Act of 2007. 
‘‘(B) Two calendar years after the date 
such payment or other transfer of value was 
made. 
‘‘(6) 
CONFIDENTIALITY.—Information 
de-
scribed in paragraph (4) or (5) shall be considered 
confidential and shall not be subject to disclosure 
under section 552 of title 5, United States Code, or 
any other similar Federal, State, or local law, until 
or after the date on which the information is made 
available to the public under such paragraph. 
‘‘(b) REPORTING OF OWNERSHIP INTEREST BY PHY-
SICIANS IN HOSPITALS AND OTHER ENTITIES THAT BILL 
MEDICARE.—Not later than March 31 of each year (be-
ginning with 2011), each hospital or other health care en-
tity (not including a Medicare Advantage organization) 
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that bills the Secretary under part A or part B of title 
XVIII for services shall report on the ownership shares 
(other than ownership shares described in section 1877(c)) 
of each physician who, directly or indirectly, owns an in-
terest in the entity. In this subsection, the term ‘physician’ 
includes a physician’s immediate family members (as de-
fined for purposes of section 1877(a)). 
‘‘(c) PUBLIC AVAILABILITY.— 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish procedures to ensure that, not later than Sep-
tember 30, 2011, and on June 30 of each year be-
ginning thereafter, the information submitted under 
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 
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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; 
‘‘(D) contains a description of any enforce-
ment actions taken to carry out this section, in-
cluding any penalties imposed under subsection 
(d), during the preceding year; 
‘‘(E) contains background information on 
industry-physician relationships; 
‘‘(F) in the case of information submitted 
with respect to a payment or other transfer of 
value described in subsection (a)(5), lists such 
information separately from the other informa-
tion submitted under subsection (a) and des-
ignates such separately listed information as 
funding for clinical research; 
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‘‘(G) contains any other information the 
Secretary determines would be helpful to the 
average consumer; and 
‘‘(H) provides the covered recipient an op-
portunity to submit corrections to the informa-
tion made available to the public with respect to 
the covered recipient. 
‘‘(2) ACCURACY OF REPORTING.—The accuracy 
of the information that is submitted under sub-
sections (a) and (b) and made available under para-
graph (1) shall be the responsibility of the applicable 
manufacturer or distributor of a covered drug, de-
vice, biological, or medical supply reporting under 
subsection (a) or hospital or other health care entity 
reporting physician ownership under subsection (b). 
The Secretary shall establish procedures to ensure 
that the covered recipient is provided with an oppor-
tunity to submit corrections to the manufacturer, 
distributor, hospital, or other entity reporting under 
subsection (a) or (b) with regard to information 
made public with respect to the covered recipient 
and, under such procedures, the corrections shall be 
transmitted to the Secretary. 
‘‘(3) SPECIAL RULE FOR DRUG SAMPLES.—In-
formation relating to drug samples provided under 
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subsection (a) shall not be made available to the 
public by the Secretary but may be made available 
outside the Department of Health and Human Serv-
ices by the Secretary for research or legitimate busi-
ness purposes pursuant to data use agreements. 
‘‘(4) SPECIAL RULE FOR NATIONAL PROVIDER 
IDENTIFIERS.—Information relating to national pro-
vider identifiers provided under subsection (a) shall 
not be made available to the public by the Secretary 
but may be made available outside the Department 
of Health and Human Services by the Secretary for 
research or legitimate business purposes pursuant to 
data use agreements. 
‘‘(d) PENALTIES FOR NONCOMPLIANCE.— 
‘‘(1) FAILURE TO REPORT.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), except as provided in paragraph (2), 
any applicable manufacturer or distributor that 
fails to submit information required under sub-
section (a) in a timely manner in accordance 
with regulations promulgated to carry out such 
subsection, and any hospital or other entity that 
fails to submit information required under sub-
section (b) in a timely manner in accordance 
with regulations promulgated to carry out such 
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subsection shall be subject to a civil money pen-
alty of not less than $1,000, but not more than 
$10,000, for each payment or other transfer of 
value or ownership or investment interest not 
reported as required under such subsection. 
Such penalty shall be imposed and collected in 
the same manner as civil money penalties under 
subsection (a) of section 1128A are imposed 
and collected under that section. 
‘‘(B) LIMITATION.—The total amount of 
civil money penalties imposed under subpara-
graph (A) with respect to each annual submis-
sion of information under subsection (a) by an 
applicable manufacturer or distributor or other 
entity shall not exceed $150,000. 
‘‘(2) KNOWING FAILURE TO REPORT.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), any applicable manufacturer or dis-
tributor that knowingly fails to submit informa-
tion required under subsection (a) in a timely 
manner in accordance with regulations promul-
gated to carry out such subsection and any hos-
pital or other entity that fails to submit infor-
mation required under subsection (b) in a time-
ly manner in accordance with regulations pro-
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mulgated to carry out such subsection, shall be 
subject to a civil money penalty of not less than 
$10,000, but not more than $100,000, for each 
payment or other transfer of value or ownership 
or investment interest not reported as required 
under such subsection. Such penalty shall be 
imposed and collected in the same manner as 
civil money penalties under subsection (a) of 
section 1128A are imposed and collected under 
that section. 
‘‘(B) LIMITATION.—The total amount of 
civil money penalties imposed under subpara-
graph (A) with respect to each annual submis-
sion of information under subsection (a) or (b) 
by an applicable manufacturer, distributor, or 
entity shall not exceed $1,000,000, or, if great-
er, 0.1 percentage of the total annual revenues 
of the manufacturer, distributor, or entity. 
‘‘(3) USE OF FUNDS.—Funds collected by the 
Secretary as a result of the imposition of a civil 
money penalty under this subsection shall be used to 
carry out this section. 
‘‘(4) ENFORCEMENT THROUGH STATE ATTOR-
NEYS GENERAL.—The attorney general of a State, 
after providing notice to the Secretary of an intent 
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to proceed under this paragraph in a specific case 
and providing the Secretary with an opportunity to 
bring an action under this subsection and the Sec-
retary declining such opportunity, may proceed 
under this subsection against a manufacturer or dis-
tributor in the State. 
‘‘(e) ANNUAL REPORT
TO CONGRESS.—Not later 
than April 1 of each year beginning with 2011, the Sec-
retary shall submit to Congress a report that includes the 
following: 
‘‘(1) The information submitted under this sec-
tion during the preceding year, aggregated for each 
applicable manufacturer or distributor of a covered 
drug, device, biological, or medical supply that sub-
mitted such information during such year. 
‘‘(2) A description of any enforcement actions 
taken to carry out this section, including any pen-
alties imposed under subsection (d), during the pre-
ceding year. 
‘‘(f) DEFINITIONS.—In this section: 
‘‘(1) APPLICABLE
MANUFACTURER; APPLICA-
BLE DISTRIBUTOR.—The term ‘applicable manufac-
turer’ means a manufacturer of a covered drug, de-
vice, biological, or medical supply, and the term ‘ap-
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plicable distributor’ means a distributor of a covered 
drug, device, or medical supply. 
‘‘(2) CLINICAL
INVESTIGATION.—The term 
‘clinical investigation’ means any experiment involv-
ing one or more human subjects, or materials de-
rived from human subjects, in which a drug or de-
vice is administered, dispensed, or used. 
‘‘(3) COVERED DRUG, DEVICE, BIOLOGICAL, OR 
MEDICAL SUPPLY.—The term ‘covered’ means, with 
respect to a drug, device, biological, or medical sup-
ply, such a drug, device, biological, or medical supply 
for which payment is available under title XVIII or 
a State plan under title XIX or XXI (or a waiver 
of such a plan). 
‘‘(4) COVERED RECIPIENT.—The term ‘covered 
recipient’ means the following: 
‘‘(A) A physician. 
‘‘(B) A physician group practice. 
‘‘(C) Any other prescriber of a covered 
drug, device, biological, or medical supply. 
‘‘(D) A pharmacy or pharmacist. 
‘‘(E) A health insurance issuer, group 
health plan, or other entity offering a health 
benefits plan, including any employee of such 
an issuer, plan, or entity. 
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‘‘(F) A pharmacy benefit manager, includ-
ing any employee of such a manager. 
‘‘(G) A hospital. 
‘‘(H) A medical school. 
‘‘(I) A sponsor of a continuing medical 
education program. 
‘‘(J) A patient advocacy or disease specific 
group. 
‘‘(K) A organization of health care profes-
sionals. 
‘‘(L) A biomedical researcher. 
‘‘(M) A group purchasing organization. 
‘‘(5) DISTRIBUTOR OF A COVERED DRUG, DE-
VICE, OR MEDICAL SUPPLY.—The term ‘distributor 
of a covered drug, device, or medical supply’ means 
any entity which is engaged in the marketing or dis-
tribution of a covered drug, device, or medical sup-
ply (or any subsidiary of or entity affiliated with 
such entity), but does not include a wholesale phar-
maceutical distributor. 
‘‘(6) EMPLOYEE.—The term ‘employee’ has the 
meaning given such term in section 1877(h)(2). 
‘‘(7) KNOWINGLY.—The term ‘knowingly’ has 
the meaning given such term in section 3729(b) of 
title 31, United States Code. 
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‘‘(8) MANUFACTURER
OF
A
COVERED
DRUG, 
DEVICE, BIOLOGICAL, OR
MEDICAL
SUPPLY.—The 
term ‘manufacturer of a covered drug, device, bio-
logical, or medical supply’ means any entity which is 
engaged in the production, preparation, propagation, 
compounding, conversion, processing, marketing, or 
distribution of a covered drug, device, biological, or 
medical supply (or any subsidiary of or entity affili-
ated with such entity). 
‘‘(9) PAYMENT
OR
OTHER
TRANSFER
OF 
VALUE.— 
‘‘(A) IN GENERAL.—The term ‘payment or 
other transfer of value’ means a transfer of 
anything of value for or of any of the following: 
‘‘(i) Gift, food, or entertainment. 
‘‘(ii) Travel or trip. 
‘‘(iii) Honoraria. 
‘‘(iv) Research funding or grant. 
‘‘(v) Education or conference funding. 
‘‘(vi) Consulting fees. 
‘‘(vii) Ownership or investment inter-
est and royalties or license fee. 
‘‘(B) INCLUSIONS.—Subject to subpara-
graph (C), the term ‘payment or other transfer 
of value’ includes any compensation, gift, hono-
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rarium, speaking fee, consulting fee, travel, 
services, dividend, profit distribution, stock or 
stock option grant, or any ownership or invest-
ment interest held by a physician in a manufac-
turer (excluding a dividend or other profit dis-
tribution from, or ownership or investment in-
terest in, a publicly traded security or mutual 
fund (as described in section 1877(c))). 
‘‘(C) EXCLUSIONS.—The term ‘payment or 
other transfer of value’ does not include the fol-
lowing: 
‘‘(i) Any payment or other transfer of 
value provided by an applicable manufac-
turer or distributor to a covered recipient 
where the amount transferred to, requested 
by, or designated on behalf of the covered 
recipient does not exceed $5. 
‘‘(ii) The loan of a covered device for 
a short-term trial period, not to exceed 90 
days, to permit evaluation of the covered 
device by the covered recipient. 
‘‘(iii) Items or services provided under 
a contractual warranty, including the re-
placement of a covered device, where the 
terms of the warranty are set forth in the 
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purchase or lease agreement for the cov-
ered device. 
‘‘(iv) A transfer of anything of value 
to a covered recipient when the covered re-
cipient is a patient and not acting in the 
professional capacity of a covered recipient. 
‘‘(v) In-kind items used for the provi-
sion of charity care. 
‘‘(vi) A dividend or other profit dis-
tribution from, or ownership or investment 
interest in, a publicly traded security and 
mutual fund (as described in section 
1877(c)). 
‘‘(vii) Compensation paid by a manu-
facturer or distributor of a covered drug, 
device, biological, or medical supply to a 
covered recipient who is directly employed 
by and works solely for such manufacturer 
or distributor. 
‘‘(viii) Any discount or cash rebate. 
‘‘(10) PHYSICIAN.—The term ‘physician’ has 
the meaning given that term in section 1861(r). For 
purposes of this section, such term does not include 
a physician who is an employee of the applicable 
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manufacturer that is required to submit information 
under subsection (a). 
‘‘(g) ANNUAL REPORTS TO STATES.—Not later than 
April 1 of each year beginning with 2011, the Secretary 
shall submit to States a report that includes a summary 
of the information submitted under subsections (a) and 
(d) during the preceding year with respect to covered re-
cipients or other hospitals and entities in the State. 
‘‘(h) RELATION TO STATE LAWS.— 
‘‘(1) IN
GENERAL.—Effective on January 1, 
2011, subject to paragraph (2), the provisions of 
this section shall preempt any law or regulation of 
a State or of a political subdivision of a State that 
requires an applicable manufacturer and applicable 
distributor (as such terms are defined in subsection 
(f)) to disclose or report, in any format, the type of 
information (described in subsection (a)) regarding a 
payment or other transfer of value provided by the 
manufacturer to a covered recipient (as so defined). 
‘‘(2) NO
PREEMPTION
OF
ADDITIONAL
RE-
QUIREMENTS.—Paragraph (1) shall not preempt any 
law or regulation of a State or of a political subdivi-
sion of a State that requires any of the following: 
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‘‘(A) The disclosure or reporting of infor-
mation not of the type required to be disclosed 
or reported under this section. 
‘‘(B) The disclosure or reporting, in any 
format, of the type of information required to 
be disclosed or reported under this section to a 
Federal, State, or local governmental agency for 
public health surveillance, investigation, or 
other public health purposes or health oversight 
purposes. 
‘‘(C) The discovery or admissibility of in-
formation described in this section in a crimi-
nal, civil, or administrative proceeding.’’. 
(b) AVAILABILITY OF INFORMATION FROM THE DIS-
CLOSURE
OF
FINANCIAL
RELATIONSHIP
REPORT 
(DFRR).—The Secretary of Health and Human Services 
shall submit to Congress a report on the full results of 
the Disclosure of Physician Financial Relationships sur-
veys required pursuant to section 5006 of the Deficit Re-
duction Act of 2005. Such report shall be submitted to 
Congress not later than the date that is 6 months after 
the date such surveys are collected and shall be made pub-
licly available on an Internet website of the Department 
of Health and Human Services. 
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Subtitle E—Public Reporting on 
Health Care-Associated Infections 
SEC. 1461. REQUIREMENT FOR PUBLIC REPORTING BY 
HOSPITALS 
AND 
AMBULATORY 
SURGICAL 
CENTERS ON HEALTH CARE-ASSOCIATED IN-
FECTIONS. 
(a) IN GENERAL.—Title XI of the Social Security Act 
is amended by inserting after section 1138 the following 
section: 
‘‘SEC. 1138A. REQUIREMENT FOR PUBLIC REPORTING BY 
HOSPITALS 
AND 
AMBULATORY 
SURGICAL 
CENTERS ON HEALTH CARE-ASSOCIATED IN-
FECTIONS. 
‘‘(a) REPORTING REQUIREMENT.— 
‘‘(1) IN GENERAL.—The Secretary shall provide 
that a hospital (as defined in subsection (g)) or am-
bulatory surgical center meeting the requirements of 
titles XVIII or XIX may participate in the programs 
established under such titles (pursuant to the appli-
cable 
provisions 
of 
law, 
including 
sections 
1866(a)(1) and 1832(a)(1)(F)(i)) only if, in accord-
ance with this section, the hospital or center reports 
such information on health care-associated infections 
that develop in the hospital or center (and such de-
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mographic information associated with such infec-
tions) as the Secretary specifies. 
‘‘(2) REPORTING PROTOCOLS.—Such informa-
tion shall be reported in accordance with reporting 
protocols established by the Secretary through the 
Director of the Centers for Disease Control and Pre-
vention (in this section referred to as the ‘CDC’) 
and to the National Healthcare Safety Network of 
the CDC or under such another reporting system of 
such Centers as determined appropriate by the Sec-
retary in consultation with such Director. 
‘‘(3) COORDINATION
WITH
HIT.—The Sec-
retary, through the Director of the CDC and the Of-
fice of the National Coordinator for Health Informa-
tion Technology, shall ensure that the transmission 
of information under this subsection is coordinated 
with systems established under the HITECH Act, 
where appropriate. 
‘‘(4) PROCEDURES TO ENSURE THE VALIDITY 
OF
INFORMATION.—The Secretary shall establish 
procedures regarding the validity of the information 
submitted under this subsection in order to ensure 
that such information is appropriately compared 
across hospitals and centers. Such procedures shall 
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address failures to report as well as errors in report-
ing. 
‘‘(5) IMPLEMENTATION.—Not later than 1 year 
after the date of enactment of this section, the Sec-
retary, through the Director of CDC, shall promul-
gate regulations to carry out this section. 
‘‘(b) PUBLIC POSTING OF INFORMATION.—The Sec-
retary shall promptly post, on the official public Internet 
site of the Department of Health and Human Services, 
the information reported under subsection (a). Such infor-
mation shall be set forth in a manner that allows for the 
comparison of information on health care-associated infec-
tions— 
‘‘(1) among hospitals and ambulatory surgical 
centers; and 
‘‘(2) by demographic information. 
‘‘(c) ANNUAL REPORT TO CONGRESS.—On an annual 
basis the Secretary shall submit to the Congress a report 
that summarizes each of the following: 
‘‘(1) The number and types of health care-asso-
ciated infections reported under subsection (a) in 
hospitals and ambulatory surgical centers during 
such year. 
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‘‘(2) Factors that contribute to the occurrence 
of such infections, including health care worker im-
munization rates. 
‘‘(3) Based on the most recent information 
available to the Secretary on the composition of the 
professional staff of hospitals and ambulatory sur-
gical centers, the number of certified infection con-
trol professionals on the staff of hospitals and ambu-
latory surgical centers. 
‘‘(4) The total increases or decreases in health 
care costs that resulted from increases or decreases 
in the rates of occurrence of each such type of infec-
tion during such year. 
‘‘(5) Recommendations, in coordination with the 
Center for Quality Improvement established under 
section 931 of the Public Health Service Act, for 
best practices to eliminate the rates of occurrence of 
each such type of infection in hospitals and ambula-
tory surgical centers. 
‘‘(d) NON-PREEMPTION OF STATE LAWS.—Nothing 
in this section shall be construed as preempting or other-
wise affecting any provision of State law relating to the 
disclosure of information on health care-associated infec-
tions or patient safety procedures for a hospital or ambu-
latory surgical center. 
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‘‘(e) HEALTH CARE-ASSOCIATED INFECTION.—For 
purposes of this section: 
‘‘(1) IN GENERAL.—The term ‘health care-asso-
ciated infection’ means an infection that develops in 
a patient who has received care in any institutional 
setting where health care is delivered and is related 
to receiving health care. 
‘‘(2) RELATED TO RECEIVING HEALTH CARE.— 
The term ‘related to receiving health care’, with re-
spect to an infection, means that the infection was 
not incubating or present at the time health care 
was provided. 
‘‘(f) APPLICATION
TO
CRITICAL
ACCESS
HOS-
PITALS.—For purposes of this section, the term ‘hospital’ 
includes a critical access hospital, as defined in section 
1861(mm)(1).’’. 
(b) EFFECTIVE DATE.—With respect to section 
1138A of the Social Security Act (as inserted by sub-
section (a) of this section), the requirement under such 
section that hospitals and ambulatory surgical centers 
submit reports takes effect on such date (not later than 
2 years after the date of the enactment of this Act) as 
the Secretary of Health and Human Services shall specify. 
In order to meet such deadline, the Secretary may imple-
ment such section through guidance or other instructions. 
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(c) GAO REPORT.—Not later than 18 months after 
the date of the enactment of this Act, the Comptroller 
General of the United States shall submit to Congress a 
report on the program established under section 1138A 
of the Social Security Act, as inserted by subsection (a). 
Such report shall include an analysis of the appropriate-
ness of the types of information required for submission, 
compliance with reporting requirements, the success of the 
validity procedures established, and any conflict or overlap 
between the reporting required under such section and any 
other reporting systems mandated by either the States or 
the Federal Government. 
(d) REPORT ON ADDITIONAL DATA.—Not later than 
18 months after the date of the enactment of this Act, 
the Secretary of Health and Human Services shall submit 
to the Congress a report on the appropriateness of expand-
ing the requirements under such section to include addi-
tional information (such as health care worker immuniza-
tion rates), in order to improve health care quality and 
patient safety. 
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1715 
TITLE M—MEDICARE GRADUATE 
MEDICAL EDUCATION 
SEC. 1501. DISTRIBUTION OF UNUSED RESIDENCY POSI-
TIONS. 
(a) IN GENERAL.—Section 1886(h) of the Social Se-
curity Act (42 U.S.C. 1395ww(h)) is amended— 
(1) in paragraph (4)(F)(i), by striking ‘‘para-
graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 
(2) in paragraph (4)(H)(i), by striking ‘‘para-
graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 
(3) in paragraph (7)(E), by inserting ‘‘and 
paragraph (8)’’ after ‘‘this paragraph’’; and 
(4) by adding at the end the following new 
paragraph: 
‘‘(8) ADDITIONAL REDISTRIBUTION OF UNUSED 
RESIDENCY POSITIONS.— 
‘‘(A) REDUCTIONS IN LIMIT BASED ON UN-
USED POSITIONS.— 
‘‘(i) PROGRAMS SUBJECT TO REDUC-
TION.—If a hospital’s reference resident 
level (specified in clause (ii)) is less than 
the otherwise applicable resident limit (as 
defined in subparagraph (C)(ii)), effective 
for portions of cost reporting periods oc-
curring on or after July 1, 2011, the oth-
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erwise applicable resident limit shall be re-
duced by 90 percent of the difference be-
tween such otherwise applicable resident 
limit and such reference resident level. 
‘‘(ii) REFERENCE RESIDENT LEVEL.— 
‘‘(I) IN
GENERAL.—Except as 
otherwise provided in a subsequent 
subclause, the reference resident level 
specified in this clause for a hospital 
is the highest resident level for any of 
the 3 most recent cost reporting peri-
ods (ending before the date of the en-
actment of this paragraph) of the hos-
pital for which a cost report has been 
settled (or, if not, submitted (subject 
to audit)), as determined by the Sec-
retary. 
‘‘(II) USE OF MOST RECENT AC-
COUNTING PERIOD TO RECOGNIZE EX-
PANSION OF EXISTING PROGRAMS.—If 
a hospital submits a timely request to 
increase its resident level due to an 
expansion, or planned expansion, of 
an existing residency training pro-
gram that is not reflected on the most 
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recent settled or submitted cost re-
port, after audit and subject to the 
discretion of the Secretary, subject to 
subclause (IV), the reference resident 
level for such hospital is the resident 
level that includes the additional resi-
dents attributable to such expansion 
or establishment, as determined by 
the Secretary. The Secretary is au-
thorized to determine an alternative 
reference resident level for a hospital 
that submitted to the Secretary a 
timely request, before the start of the 
2009–2010 academic year, for an in-
crease in its reference resident level 
due to a planned expansion. 
‘‘(III) 
SPECIAL
PROVIDER 
AGREEMENT.—In the case of a hos-
pital 
described 
in 
paragraph 
(4)(H)(v), the reference resident level 
specified in this clause is the limita-
tion applicable under subclause (I) of 
such paragraph. 
‘‘(IV) 
PREVIOUS
REDISTRIBU-
TION.—The reference resident level 
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specified in this clause for a hospital 
shall be increased to the extent re-
quired to take into account an in-
crease in resident positions made 
available to the hospital under para-
graph (7)(B) that are not otherwise 
taken into account under a previous 
subclause. 
‘‘(iii) AFFILIATION.—The provisions 
of clause (i) shall be applied to hospitals 
which are members of the same affiliated 
group (as defined by the Secretary under 
paragraph (4)(H)(ii)) and to the extent the 
hospitals can demonstrate that they are 
filling any additional
resident slots allo-
cated to other hospitals through an affili-
ation agreement, the Secretary shall adjust 
the determination of available slots accord-
ingly, or which the Secretary otherwise has 
permitted the resident positions (under 
section 402 of the Social Security Amend-
ments of 1967) to be aggregated for pur-
poses of applying the resident position lim-
itations under this subsection. 
‘‘(B) REDISTRIBUTION.— 
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‘‘(i) IN
GENERAL.—The Secretary 
shall increase the otherwise applicable resi-
dent limit for each qualifying hospital that 
submits an application under this subpara-
graph by such number as the Secretary 
may approve for portions of cost reporting 
periods occurring on or after July 1, 2011. 
The estimated aggregate number of in-
creases in the otherwise applicable resident 
limit under this subparagraph may not ex-
ceed the Secretary’s estimate of the aggre-
gate reduction in such limits attributable 
to subparagraph (A). 
‘‘(ii) REQUIREMENTS
FOR
QUALI-
FYING
HOSPITALS.—A hospital is not a 
qualifying hospital for purposes of this 
paragraph unless the following require-
ments are met: 
‘‘(I) MAINTENANCE OF PRIMARY 
CARE
RESIDENT
LEVEL.—The hos-
pital maintains the number of primary 
care residents at a level that is not 
less than the base level of primary 
care residents increased by the num-
ber of additional primary care resi-
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dent positions provided to the hospital 
under this subparagraph. For pur-
poses of this subparagraph, the ‘base 
level of primary care residents’ for a 
hospital is the level of such residents 
as of a base period (specified by the 
Secretary), determined without regard 
to whether such positions were in ex-
cess of the otherwise applicable resi-
dent limit for such period but taking 
into account the application of sub-
clauses (II) and (III) of subparagraph 
(A)(ii). 
‘‘(II) DEDICATED
ASSIGNMENT 
OF ADDITIONAL RESIDENT POSITIONS 
TO PRIMARY CARE.—The hospital as-
signs all such additional resident posi-
tions for primary care residents. 
‘‘(III) 
ACCREDITATION.—The 
hospital’s residency programs in pri-
mary care are fully accredited or, in 
the case of a residency training pro-
gram not in operation as of the base 
year, the hospital is actively applying 
for such accreditation for the program 
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for such additional resident positions 
(as determined by the Secretary). 
‘‘(iii) CONSIDERATIONS
IN
REDIS-
TRIBUTION.—In determining for which 
qualifying hospitals the increase in the oth-
erwise applicable resident limit is provided 
under this subparagraph, the Secretary 
shall take into account the demonstrated 
likelihood of the hospital filling the posi-
tions within the first 3 cost reporting peri-
ods beginning on or after July 1, 2011, 
made available under this subparagraph, 
as determined by the Secretary. 
‘‘(iv) PRIORITY
FOR
CERTAIN
HOS-
PITALS.—In determining for which quali-
fying hospitals the increase in the other-
wise applicable resident limit is provided 
under this subparagraph, the Secretary 
shall distribute the increase to qualifying 
hospitals based on the following criteria: 
‘‘(I) The Secretary shall give 
preference to hospitals that had a re-
duction in resident training positions 
under subparagraph (A). 
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‘‘(II) The Secretary shall give 
preference to hospitals with 3-year 
primary care residency training pro-
grams, such as family practice and 
general internal medicine. 
‘‘(III) The Secretary shall give 
preference to hospitals insofar as they 
have in effect formal arrangements 
(as determined by the Secretary) that 
place greater emphasis upon training 
in Federally qualified health centers, 
rural health clinics, and other nonpro-
vider settings, and to hospitals that 
receive additional payments under 
subsection (d)(5)(F) and emphasize 
training in an outpatient department. 
‘‘(IV) The Secretary shall give 
preference to hospitals with a number 
of positions (as of July 1, 2009) in 
excess of the otherwise applicable resi-
dent limit for such period. 
‘‘(V) The Secretary shall give 
preference to hospitals that place 
greater emphasis upon training in a 
health professional shortage area (des-
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ignated under section 332 of the Pub-
lic Health Service Act) or a health 
professional needs area (designated 
under section 2211 of such Act). 
‘‘(VI) The Secretary shall give 
preference to hospitals in States that 
have low resident-to-population ratios 
(including a greater preference for 
those States with lower resident-to- 
population ratios). 
‘‘(v) LIMITATION.—In no case shall 
more than 20 full-time equivalent addi-
tional residency positions be made available 
under this subparagraph with respect to 
any hospital. 
‘‘(vi) APPLICATION OF PER RESIDENT 
AMOUNTS FOR PRIMARY CARE.—With re-
spect to additional residency positions in a 
hospital attributable to the increase pro-
vided under this subparagraph, the ap-
proved FTE resident amounts are deemed 
to be equal to the hospital per resident 
amounts for primary care and nonprimary 
care computed under paragraph (2)(D) for 
that hospital. 
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‘‘(vi) DISTRIBUTION.—The Secretary 
shall distribute the increase in resident 
training positions to qualifying hospitals 
under this subparagraph not later than 
July 1, 2011. 
‘‘(C) RESIDENT
LEVEL
AND
LIMIT
DE-
FINED.—In this paragraph: 
‘‘(i) The term ‘resident level’ has the 
meaning given such term in paragraph 
(7)(C)(i). 
‘‘(ii) The term ‘otherwise applicable 
resident limit’ means, with respect to a 
hospital, the limit otherwise applicable 
under subparagraphs (F)(i) and (H) of 
paragraph (4) on the resident level for the 
hospital determined without regard to this 
paragraph but taking into account para-
graph (7)(A). 
‘‘(D) MAINTENANCE
OF
PRIMARY
CARE 
RESIDENT LEVEL.—In carrying out this para-
graph, the Secretary shall require hospitals that 
receive additional resident positions under sub-
paragraph (B)— 
‘‘(i) to maintain records, and periodi-
cally report to the Secretary, on the num-
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ber of primary care residents in its resi-
dency training programs; and 
‘‘(ii) as a condition of payment for a 
cost reporting period under this subsection 
for such positions, to maintain the level of 
such positions at not less than the sum 
of— 
‘‘(I) the base level of primary 
care resident positions (as determined 
under subparagraph (B)(ii)(I)) before 
receiving such additional positions; 
and 
‘‘(II) the number of such addi-
tional positions.’’. 
(b) IME.— 
(1) IN GENERAL.—Section 1886(d)(5)(B)(v) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395ww(d)(5)(B)(v)), in the second sentence, is 
amended— 
(A) by striking ‘‘subsection (h)(7)’’ and in-
serting ‘‘subsections (h)(7) and (h)(8)’’; and 
(B) by striking ‘‘it applies’’ and inserting 
‘‘they apply’’. 
(2) 
CONFORMING
PROVISION.—Section 
1886(d)(5)(B) of the Social Security Act (42 U.S.C. 
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1395ww(d)(5)(B)) is amended by adding at the end 
the following clause: 
‘‘(x) For discharges occurring on or after July 1, 
2011, insofar as an additional payment amount under this 
subparagraph is attributable to resident positions distrib-
uted to a hospital under subsection (h)(8)(B), the indirect 
teaching adjustment factor shall be computed in the same 
manner as provided under clause (ii) with respect to such 
resident positions.’’. 
(c) CONFORMING AMENDMENT.—Section 422(b)(2) 
of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (Public Law 108–173) is 
amended by striking ‘‘section 1886(h)(7)’’ and all that fol-
lows and inserting ‘‘paragraphs (7) and (8) of subsection 
(h) of section 1886 of the Social Security Act’’. 
SEC. 1502. INCREASING TRAINING IN NONPROVIDER SET-
TINGS. 
(a) DIRECT GME.—Section 1886(h)(4)(E) of the So-
cial Security Act (42 U.S.C. 1395ww(h)) is amended— 
(1) by designating the first sentence as a clause 
(i) with the heading ‘‘IN GENERAL’’ and appropriate 
indentation; 
(2) by striking ‘‘shall be counted and that all 
the time’’ and inserting ‘‘shall be counted and 
that— 
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‘‘(I) effective for cost reporting 
periods beginning before July 1, 2009, 
all the time’’; 
(3) in subclause (I), as inserted by paragraph 
(1), by striking the period at the end and inserting 
‘‘; and’’; and 
(A) by inserting after subclause (I), as so 
inserted, the following: 
‘‘(II) effective for cost reporting 
periods beginning on or after July 1, 
2009, all the time so spent by a resi-
dent shall be counted towards the de-
termination of full-time equivalency, 
without regard to the setting in which 
the activities are performed, if the 
hospital incurs the costs of the sti-
pends and fringe benefits of the resi-
dent during the time the resident 
spends in that setting. 
Any hospital claiming under this subpara-
graph for time spent in a nonprovider set-
ting shall maintain and make available to 
the 
Secretary 
records 
regarding 
the 
amount of such time and such amount in 
comparison with amounts of such time in 
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such base year as the Secretary shall speci-
fy.’’. 
(b) IME.—Section 1886(d)(5)(B)(iv) of the Social 
Security Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amend-
ed— 
(1) by striking ‘‘(iv) Effective for discharges oc-
curring on or after October 1, 1997’’ and inserting 
‘‘(iv)(I) Effective for discharges occurring on or 
after October 1, 1997, and before July 1, 2009’’; 
and 
(2) by inserting after subclause (I), as inserted 
by paragraph (1), the following new subclause: 
‘‘(II) Effective for discharges occurring on or 
after July 1, 2009, all the time spent by an intern 
or resident in patient care activities at an entity in 
a nonprovider setting shall be counted towards the 
determination of full-time equivalency if the hospital 
incurs the costs of the stipends and fringe benefits 
of the intern or resident during the time the intern 
or resident spends in that setting.’’. 
(c) OIG STUDY ON IMPACT ON TRAINING.—The In-
spector General of the Department of Health and Human 
Services shall analyze the data collected by the Secretary 
of Health and Human Services from the records made 
available to the Secretary under section 1886(h)(4)(E) of 
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the Social Security Act, as amended by subsection (a), in 
order to assess the extent to which there is an increase 
in time spent by medical residents in training in nonpro-
vider settings as a result of the amendments made by this 
section. Not later than 4 years after the date of the enact-
ment of this Act, the Inspector General shall submit a re-
port to Congress on such analysis and assessment. 
(d) DEMONSTRATION
PROJECT
FOR
APPROVED 
TEACHING HEALTH CENTERS.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services shall conduct a demonstration 
project under which an approved teaching health 
center (as defined in paragraph (3)) would be eligi-
ble for payment under subsections (h) and (k) of 
section 1886 of the Social Security Act (42 U.S.C. 
1395ww) of amounts for its own direct costs of 
graduate medical education activities for primary 
care residents, as well as for the direct costs of grad-
uate medical education activities of its contracting 
hospital for such residents, in a manner similar to 
the manner in which such payments would be made 
to a hospital if the hospital were to operate such a 
program. 
(2) CONDITIONS.—Under the demonstration 
project— 
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(A) an approved teaching health center 
shall contract with an accredited teaching hos-
pital to carry out the inpatient responsibilities 
of the primary care residency program of the 
hospital involved and is responsible for payment 
to the hospital for the hospital’s costs of the 
salary and fringe benefits for residents in the 
program; 
(B) the number of primary care residents 
of the center shall not count against the con-
tracting hospital’s resident limit; and 
(C) the contracting hospital shall agree not 
to diminish the number of residents in its pri-
mary care residency training program. 
(3) APPROVED TEACHING HEALTH CENTER DE-
FINED.—In this subsection, the term ‘‘approved 
teaching health center’’ means a nonprovider setting, 
such as a Federally qualified health center or rural 
health clinic (as defined in section 1861(aa) of the 
Social Security Act), that develops and operates an 
accredited primary care residency program for which 
funding would be available if it were operated by a 
hospital. 
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SEC. 1503. RULES FOR COUNTING RESIDENT TIME FOR DI-
DACTIC AND SCHOLARLY ACTIVITIES AND 
OTHER ACTIVITIES. 
(a) DIRECT GME.—Section 1886(h) of the Social Se-
curity Act (42 U.S.C. 1395ww(h)) is amended— 
(1) in paragraph (4)(E), as amended by section 
1502(a)— 
(A) in clause (i), by striking ‘‘Such rules’’ 
and inserting ‘‘Subject to clause (ii), such 
rules’’; and 
(B) by adding at the end the following new 
clause: 
‘‘(ii) TREATMENT OF CERTAIN NON-
PROVIDER
AND
DIDACTIC
ACTIVITIES.— 
Such rules shall provide that all time spent 
by an intern or resident in an approved 
medical residency training program in a 
nonprovider setting that is primarily en-
gaged in furnishing patient care (as de-
fined in paragraph (5)(K)) in nonpatient 
care activities, such as didactic conferences 
and seminars, but not including research 
not associated with the treatment or diag-
nosis of a particular patient, as such time 
and activities are defined by the Secretary, 
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shall be counted toward the determination 
of full-time equivalency.’’; 
(2) in paragraph (4), by adding at the end the 
following new subparagraph: 
‘‘(I) In determining the hospital’s number 
of full-time equivalent residents for purposes of 
this subsection, all the time that is spent by an 
intern or resident in an approved medical resi-
dency training program on vacation, sick leave, 
or other approved leave, as such time is defined 
by the Secretary, and that does not prolong the 
total time the resident is participating in the 
approved program beyond the normal duration 
of the program shall be counted toward the de-
termination of full-time equivalency.’’; and 
(3) in paragraph (5), by adding at the end the 
following new subparagraph: 
‘‘(K) NONPROVIDER SETTING THAT IS PRI-
MARILY
ENGAGED
IN
FURNISHING
PATIENT 
CARE.—The term ‘nonprovider setting that is 
primarily engaged in furnishing patient care’ 
means a nonprovider setting in which the pri-
mary activity is the care and treatment of pa-
tients, as defined by the Secretary.’’. 
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(b) IME DETERMINATIONS.—Section 1886(d)(5)(B) 
of such Act (42 U.S.C. 1395ww(d)(5)(B)), as amended by 
section 1501(b), is amended by adding at the end the fol-
lowing new clause: 
‘‘(xi)(I) The provisions of subparagraph (I) of sub-
section (h)(4) shall apply under this subparagraph in the 
same manner as they apply under such subsection. 
‘‘(II) In determining the hospital’s number of full- 
time equivalent residents for purposes of this subpara-
graph, all the time spent by an intern or resident in an 
approved medical residency training program in non-
patient care activities, such as didactic conferences and 
seminars, as such time and activities are defined by the 
Secretary, that occurs in the hospital shall be counted to-
ward the determination of full-time equivalency if the hos-
pital— 
‘‘(aa) is recognized as a subsection (d) hospital; 
‘‘(bb) is recognized as a subsection (d) Puerto 
Rico hospital; 
‘‘(cc) is reimbursed under a reimbursement sys-
tem authorized under section 1814(b)(3); or 
‘‘(dd) is a provider-based hospital outpatient de-
partment. 
‘‘(III) In determining the hospital’s number of full- 
time equivalent residents for purposes of this subpara-
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graph, all the time spent by an intern or resident in an 
approved medical residency training program in research 
activities that are not associated with the treatment or di-
agnosis of a particular patient, as such time and activities 
are defined by the Secretary, shall not be counted toward 
the determination of full-time equivalency.’’. 
(c) EFFECTIVE DATES; APPLICATION.— 
(1) IN
GENERAL.—Except as otherwise pro-
vided, the Secretary of Health and Human Services 
shall implement the amendments made by this sec-
tion in a manner so as to apply to cost reporting pe-
riods beginning on or after January 1, 1983. 
(2) DIRECT GME.—Section 1886(h)(4)(E)(ii) of 
the Social Security Act, as added by subsection 
(a)(1)(B), shall apply to cost reporting periods be-
ginning on or after July 1, 2008. 
(3) IME.—Section 1886(d)(5)(B)(x)(III) of the 
Social Security Act, as added by subsection (b), shall 
apply to cost reporting periods beginning on or after 
October 1, 2001. Such section, as so added, shall 
not give rise to any inference on how the law in ef-
fect prior to such date should be interpreted. 
(4) APPLICATION.—The amendments made by 
this section shall not be applied in a manner that re-
quires reopening of any settled hospital cost reports 
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as to which there is not a jurisdictionally proper ap-
peal pending as of the date of the enactment of this 
Act on the issue of payment for indirect costs of 
medical education under section 1886(d)(5)(B) of 
the Social Security Act or for direct graduate med-
ical education costs under section 1886(h) of such 
Act. 
SEC. 1504. PRESERVATION OF RESIDENT CAP POSITIONS 
FROM CLOSED HOSPITALS. 
(a) DIRECT GME.—Section 1886(h)(4)(H) of the So-
cial Security Act (42 U.S.C. Section 1395ww(h)(4)(H)) 
is amended by adding at the end the following new clause: 
‘‘(vi) REDISTRIBUTION OF RESIDENCY 
SLOTS AFTER A HOSPITAL CLOSES.— 
‘‘(I) IN
GENERAL.—The Sec-
retary shall, by regulation, establish a 
process consistent with subclauses (II) 
and (III) under which, in the case 
where a hospital (other than a hos-
pital described in clause (v)) with an 
approved medical residency program 
in a State closes on or after the date 
that is 2 years before the date of the 
enactment of this clause, the Sec-
retary shall increase the otherwise ap-
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plicable resident limit under this para-
graph for other hospitals in the State 
in accordance with this clause. 
‘‘(II) PROCESS
FOR
HOSPITALS 
IN CERTAIN AREAS.—In determining 
for which hospitals the increase in the 
otherwise applicable resident limit de-
scribed in subclause (I) is provided, 
the Secretary shall establish a process 
to provide for such increase to one or 
more hospitals located in the State. 
Such process shall take into consider-
ation the recommendations submitted 
to the Secretary by the senior health 
official (as designated by the chief ex-
ecutive officer of such State) if such 
recommendations are submitted not 
later than 180 days after the date of 
the hospital closure involved (or, in 
the case of a hospital that closed after 
the date that is 2 years before the 
date of the enactment of this clause, 
180 days after such date of enact-
ment). 
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‘‘(III) LIMITATION.—The esti-
mated aggregate number of increases 
in the otherwise applicable resident 
limits for hospitals under this clause 
shall be equal to the estimated num-
ber of resident positions in the ap-
proved medical residency programs 
that closed on or after the date de-
scribed in subclause (I).’’. 
(b) NO EFFECT ON TEMPORARY FTE CAP ADJUST-
MENTS.—The amendments made by this section shall not 
effect any temporary adjustment to a hospital’s FTE cap 
under section 413.79(h) of title 42, Code of Federal Regu-
lations (as in effect on the date of enactment of this Act) 
and 
shall 
not 
affect 
the 
application 
of 
section 
1886(h)(4)(H)(v) of the Social Security Act. 
(c) CONFORMING AMENDMENTS.— 
(1) Section 422(b)(2) of the Medicare Prescrip-
tion Drug, Improvement, and Modernization Act of 
2003 (Public Law 108–173), as amended by section 
1501(c), is amended by striking ‘‘(7) and’’ and in-
serting ‘‘(4)(H)(vi), (7), and’’. 
(2) Section 1886(h)(7)(E) of the Social Secu-
rity Act (42 U.S.C. 1395ww(h)(7)(E)) is amended 
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by inserting ‘‘or under paragraph (4)(H)(vi)’’ after 
‘‘under this paragraph’’. 
SEC. 1505. IMPROVING ACCOUNTABILITY FOR APPROVED 
MEDICAL RESIDENCY TRAINING. 
(a) SPECIFICATION OF GOALS FOR APPROVED MED-
ICAL
RESIDENCY
TRAINING
PROGRAMS.—Section 
1886(h)(1) of the Social Security Act (42 U.S.C. 
1395ww(h)(1)) is amended— 
(1) by designating the matter beginning with 
‘‘Notwithstanding’’ as a subparagraph (A) with the 
heading ‘‘IN GENERAL.—’’ and with appropriate in-
dentation; and 
(2) by adding at the end the following new 
paragraph: 
‘‘(B) GOALS
AND
ACCOUNTABILITY
FOR 
APPROVED MEDICAL RESIDENCY TRAINING PRO-
GRAMS.—The goals of medical residency train-
ing programs are to foster a physician work-
force so that physicians are trained to be able 
to do the following: 
‘‘(i) Work effectively in various health 
care delivery settings, such as nonprovider 
settings. 
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‘‘(ii) Coordinate patient care within 
and across settings relevant to their spe-
cialties. 
‘‘(iii) Understand the relevant cost 
and value of various diagnostic and treat-
ment options. 
‘‘(iv) Work in inter-professional teams 
and multi-disciplinary team-based models 
in provider and nonprovider settings to en-
hance safety and improve quality of patient 
care. 
‘‘(v) Be knowledgeable in methods of 
identifying systematic errors in health care 
delivery and in implementing systematic 
solutions in case of such errors, including 
experience and participation in continuous 
quality improvement projects to improve 
health outcomes of the population the phy-
sicians serve. 
‘‘(vi) Be meaningful EHR users (as 
determined under section 1848(o)(2)) in 
the delivery of care and in improving the 
quality of the health of the community and 
the individuals that the hospital serves.’’ 
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(b) GAO STUDY ON EVALUATION OF TRAINING PRO-
GRAMS.— 
(1) IN GENERAL.—The Comptroller General of 
the United States shall conduct a study to evaluate 
the extent to which medical residency training pro-
grams— 
(A) are meeting the goals described in sec-
tion 1886(h)(1)(B) of the Social Security Act, 
as added by subsection (a), in a range of resi-
dency programs, including primary care and 
other specialties; and 
(B) have the appropriate faculty expertise 
to teach the topics required to achieve such 
goals. 
(2) REPORT.—Not later than 18 months after 
the date of the enactment of this Act, the Comp-
troller General shall submit to Congress a report on 
such study and shall include in such report rec-
ommendations as to how medical residency training 
programs could be further encouraged to meet such 
goals through means such as— 
(A) development of curriculum require-
ments; and 
(B) assessment of the accreditation proc-
esses of the Accreditation Council for Graduate 
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Medical Education and the American Osteo-
pathic Association and effectiveness of those 
processes in accrediting medical residency pro-
grams that meet the goals referred to in para-
graph (1)(A). 
TITLE N—PROGRAM INTEGRITY 
Subtitle A—Increased Funding To 
Fight Waste, Fraud, and Abuse 
SEC. 1601. INCREASED FUNDING AND FLEXIBILITY TO 
FIGHT FRAUD AND ABUSE. 
(a) IN GENERAL.—Section 1817(k) of the Social Se-
curity Act (42 U.S.C. 1395i(k)) is amended— 
(1) by adding at the end the following new 
paragraph: 
‘‘(7) ADDITIONAL FUNDING.—In addition to the 
funds otherwise appropriated to the Account from 
the Trust Fund under paragraphs (3) and (4) and 
for purposes described in paragraphs (3)(C) and 
(4)(A), there are hereby appropriated an additional 
$100,000,000 to such Account from such Trust 
Fund for each fiscal year beginning with 2011. The 
funds appropriated under this paragraph shall be al-
located in the same proportion as the total funding 
appropriated with respect to paragraphs (3)(A) and 
(4)(A) was allocated with respect to fiscal year 
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2010, and shall be available without further appro-
priation until expended.’’. 
(2) in paragraph (4)(A)— 
(A) by inserting ‘‘for activities described in 
paragraph (3)(C) and’’ after ‘‘necessary’’; and 
(B) by inserting ‘‘until expended’’ after 
‘‘appropriation’’. 
(b) 
FLEXIBILITY
IN
PURSUING
FRAUD
AND 
ABUSE.—Section 1893(a) of the Social Security Act (42 
U.S.C. 1395ddd(a)) is amended by inserting ‘‘, or other-
wise,’’ after ‘‘entities’’. 
Subtitle B—Enhanced Penalties for 
Fraud and Abuse 
SEC. 1611. ENHANCED PENALTIES FOR FALSE STATEMENTS 
ON PROVIDER OR SUPPLIER ENROLLMENT 
APPLICATIONS. 
(a) IN GENERAL.—Section 1128A(a) of the Social 
Security Act (42 U.S.C. 1320a–7a(a)) is amended— 
(1) in paragraph (1)(D), by striking all that fol-
lows ‘‘in which the person was excluded’’ and insert-
ing ‘‘under Federal law from the Federal health care 
program under which the claim was made, or’’; 
(2) by striking ‘‘or’’ at the end of paragraph 
(6); 
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(3) in paragraph (7), by inserting at the end 
‘‘or’’; 
(4) by inserting after paragraph (7) the fol-
lowing new paragraph: 
‘‘(8) knowingly makes or causes to be made any 
false statement, omission, or misrepresentation of a 
material fact in any application, agreement, bid, or 
contract to participate or enroll as a provider of 
services or supplier under a Federal health care pro-
gram, including managed care organizations under 
title XIX, Medicare Advantage organizations under 
part C of title XVIII, prescription drug plan spon-
sors under part D of title XVIII, and entities that 
apply to participate as providers of services or sup-
pliers in such managed care organizations and such 
plans;’’; 
(5) in the matter following paragraph (8), as 
inserted by paragraph (4), by striking ‘‘or in cases 
under paragraph (7), $50,000 for each such act)’’ 
and inserting ‘‘in cases under paragraph (7), 
$50,000 for each such act, or in cases under para-
graph (8), $50,000 for each false statement, omis-
sion, or misrepresentation of a material fact)’’; and 
(6) in the second sentence, by striking ‘‘for a 
lawful purpose)’’ and inserting ‘‘for a lawful pur-
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pose, or in cases under paragraph (8), an assess-
ment of not more than 3 times the amount claimed 
as the result of the false statement, omission, or 
misrepresentation of material fact claimed by a pro-
vider of services or supplier whose application to 
participate contained such false statement, omission, 
or misrepresentation)’’. 
(b) EFFECTIVE DATE.—The amendments made by 
subsection (a) shall apply to acts committed on or after 
January 1, 2010. 
SEC. 1612. ENHANCED PENALTIES FOR SUBMISSION OF 
FALSE STATEMENTS MATERIAL TO A FALSE 
CLAIM. 
(a) IN GENERAL.—Section 1128A(a) of the Social 
Security Act (42 U.S.C. 1320a–7a(a)), as amended by sec-
tion 1611, is further amended— 
(1) in paragraph (7), by striking ‘‘or’’ at the 
end; 
(2) in paragraph (8), by inserting ‘‘or’’ at the 
end; and 
(3) by inserting after paragraph (8), the fol-
lowing new paragraph: 
‘‘(9) knowingly makes, uses, or causes to be 
made or used, a false record or statement material 
to a false or fraudulent claim for payment for items 
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and services furnished under a Federal health care 
program;’’; and 
(4) in the matter following paragraph (9), as 
inserted by paragraph (3)— 
(A) by striking ‘‘or in cases under para-
graph (8)’’ and inserting ‘‘in cases under para-
graph (8)’’; and 
(B) by striking ‘‘a material fact)’’ and in-
serting ‘‘a material fact, in cases under para-
graph (9), $50,000 for each false record or 
statement)’’. 
(b) EFFECTIVE DATE.—The amendments made by 
subsection (a) shall apply to acts committed on or after 
January 1, 2010. 
SEC. 1613. ENHANCED PENALTIES FOR DELAYING INSPEC-
TIONS. 
(a) IN GENERAL.—Section 1128A(a) of the Social 
Security Act (42 U.S.C. 1320a–7a(a)), as amended by sec-
tions 1611 and 1612, is further amended— 
(1) in paragraph (8), by striking ‘‘or’’ at the 
end; 
(2) in paragraph (9), by inserting ‘‘or’’ at the 
end; 
(3) by inserting after paragraph (9) the fol-
lowing new paragraph: 
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‘‘(10) fails to grant timely access, upon reason-
able request (as defined by the Secretary in regula-
tions), to the Inspector General of the Department 
of Health and Human Services, for the purpose of 
audits, investigations, evaluations, or other statutory 
functions of the Inspector General of the Depart-
ment of Health and Human Services;’’; and 
(4) in the matter following paragraph (10), as 
inserted by paragraph (3)— 
(A) by striking ‘‘or’’ after ‘‘$50,000 for 
each such act,’’; and 
(B) by inserting ‘‘, or in cases under para-
graph (10), $15,000 for each day of the failure 
described in such paragraph’’ after ‘‘false 
record or statement’’. 
(b) ENSURING TIMELY INSPECTIONS RELATING TO 
CONTRACTS
WITH
MA 
ORGANIZATIONS.—Section 
1857(d)(2) of such Act (42 U.S.C. 1395w–27(d)(2)) is 
amended— 
(1) in subparagraph (A), by inserting ‘‘timely’’ 
before ‘‘inspect’’; and 
(2) in subparagraph (B), by inserting ‘‘timely’’ 
before ‘‘audit and inspect’’. 
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(c) EFFECTIVE DATE.—The amendments made by 
subsection (a) shall apply to violations committed on or 
after January 1, 2010. 
SEC. 1614. ENHANCED HOSPICE PROGRAM SAFEGUARDS. 
(a) MEDICARE.—Part A of title XVIII of the Social 
Security Act is amended by inserting after section 1819 
the following new section: 
‘‘SEC. 1819A. ASSURING QUALITY OF CARE IN HOSPICE 
CARE. 
‘‘(a) IN GENERAL.—If the Secretary determines on 
the basis of a survey or otherwise, that a hospice program 
that is certified for participation under this title has dem-
onstrated a substandard quality of care and failed to meet 
such other requirements as the Secretary may find nec-
essary in the interest of the health and safety of the indi-
viduals who are provided care and services by the agency 
or organization involved and determines— 
‘‘(1) that the deficiencies involved immediately 
jeopardize the health and safety of the individuals to 
whom the program furnishes items and services, the 
Secretary shall take immediate action to remove the 
jeopardy and correct the deficiencies through the 
remedy specified in subsection (b)(2)(A)(iii) or ter-
minate the certification of the program, and may 
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provide, in addition, for 1 or more of the other rem-
edies described in subsection (b)(2)(A); or 
‘‘(2) that the deficiencies involved do not imme-
diately jeopardize the health and safety of the indi-
viduals to whom the program furnishes items and 
services, the Secretary may— 
‘‘(A) impose intermediate sanctions devel-
oped pursuant to subsection (b), in lieu of ter-
minating the certification of the program; and 
‘‘(B) if, after such a period of intermediate 
sanctions, the program is still not in compliance 
with such requirements, the Secretary shall ter-
minate the certification of the program. 
If the Secretary determines that a hospice program 
that is certified for participation under this title is 
in compliance with such requirements but, as of a 
previous period, was not in compliance with such re-
quirements, the Secretary may provide for a civil 
money penalty under subsection (b)(2)(A)(i) for the 
days in which it finds that the program was not in 
compliance with such requirements. 
‘‘(b) INTERMEDIATE SANCTIONS.— 
‘‘(1) DEVELOPMENT AND IMPLEMENTATION.— 
The Secretary shall develop and implement, by not 
later than July 1, 2012— 
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‘‘(A) a range of intermediate sanctions to 
apply to hospice programs under the conditions 
described in subsection (a), and 
‘‘(B) appropriate procedures for appealing 
determinations relating to the imposition of 
such sanctions. 
‘‘(2) SPECIFIED SANCTIONS.— 
‘‘(A) 
IN
GENERAL.—The 
intermediate 
sanctions developed under paragraph (1) may 
include— 
‘‘(i) civil money penalties in an 
amount not to exceed $10,000 for each day 
of noncompliance or, in the case of a per 
instance penalty applied by the Secretary, 
not to exceed $25,000, 
‘‘(ii) denial of all or part of the pay-
ments to which a hospice program would 
otherwise be entitled under this title with 
respect to items and services furnished by 
a hospice program on or after the date on 
which the Secretary determines that inter-
mediate sanctions should be imposed pur-
suant to subsection (a)(2), 
‘‘(iii) the appointment of temporary 
management to oversee the operation of 
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the hospice program and to protect and as-
sure the health and safety of the individ-
uals under the care of the program while 
improvements are made, 
‘‘(iv) corrective action plans, and 
‘‘(v) in-service training for staff. 
The provisions of section 1128A (other than 
subsections (a) and (b)) shall apply to a civil 
money penalty under clause (i) in the same 
manner as such provisions apply to a penalty or 
proceeding under section 1128A(a). The tem-
porary management under clause (iii) shall not 
be terminated until the Secretary has deter-
mined that the program has the management 
capability to ensure continued compliance with 
all requirements referred to in that clause. 
‘‘(B) 
CLARIFICATION.—The 
sanctions 
specified in subparagraph (A) are in addition to 
sanctions otherwise available under State or 
Federal law and shall not be construed as lim-
iting other remedies, including any remedy 
available to an individual at common law. 
‘‘(C) COMMENCEMENT
OF
PAYMENT.—A 
denial of payment under subparagraph (A)(ii) 
shall terminate when the Secretary determines 
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that the hospice program no longer dem-
onstrates a substandard quality of care and 
meets such other requirements as the Secretary 
may find necessary in the interest of the health 
and safety of the individuals who are provided 
care and services by the agency or organization 
involved. 
‘‘(3) SECRETARIAL AUTHORITY.—The Secretary 
shall develop and implement, by not later than July 
1, 2011, specific procedures with respect to the con-
ditions under which each of the intermediate sanc-
tions developed under paragraph (1) is to be applied, 
including the amount of any fines and the severity 
of each of these sanctions. Such procedures shall be 
designed so as to minimize the time between identi-
fication of deficiencies and imposition of these sanc-
tions and shall provide for the imposition of incre-
mentally more severe fines for repeated or uncor-
rected deficiencies.’’. 
(b) APPLICATION TO MEDICAID.—Section 1905(o) of 
the Social Security Act (42 U.S.C. 1396d(o)) is amended 
by adding at the end the following new paragraph: 
‘‘(4) The provisions of section 1819A shall apply to 
a hospice program providing hospice care under this title 
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in the same manner as such provisions apply to a hospice 
program providing hospice care under title XVIII.’’. 
(c) APPLICATION TO CHIP.—Title XXI of the Social 
Security Act is amended by adding at the end the fol-
lowing new section: 
‘‘SEC. 2114. ASSURING QUALITY OF CARE IN HOSPICE CARE. 
‘‘The provisions of section 1819A shall apply to a 
hospice program providing hospice care under this title in 
the same manner such provisions apply to a hospice pro-
gram providing hospice care under title XVIII.’’. 
SEC. 1615. ENHANCED PENALTIES FOR INDIVIDUALS EX-
CLUDED FROM PROGRAM PARTICIPATION. 
(a) IN GENERAL.—Section 1128A(a) of the Social 
Security Act (42 U.S.C. 1320a–7a(a)), as amended by the 
previous sections, is further amended— 
(1) by striking ‘‘or’’ at the end of paragraph 
(9); 
(2) by inserting ‘‘or’’ at the end of paragraph 
(10); 
(3) by inserting after paragraph (10) the fol-
lowing new paragraph: 
‘‘(11) orders or prescribes an item or service, 
including without limitation home health care, diag-
nostic and clinical lab tests, prescription drugs, du-
rable medical equipment, ambulance services, phys-
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ical or occupational therapy, or any other item or 
service, during a period when the person has been 
excluded from participation in a Federal health care 
program, and the person knows or should know that 
a claim for such item or service will be presented to 
such a program;’’; and 
(4) in the matter following paragraph (11), as 
inserted by paragraph (2), by striking ‘‘$15,000 for 
each day of the failure described in such paragraph’’ 
and inserting ‘‘$15,000 for each day of the failure 
described in such paragraph, or in cases under para-
graph (11), $50,000 for each order or prescription 
for an item or service by an excluded individual’’. 
(b) EFFECTIVE DATE.—The amendments made by 
subsection (a) shall apply to violations committed on or 
after January 1, 2010. 
SEC. 1616. ENHANCED PENALTIES FOR PROVISION OF 
FALSE INFORMATION BY MEDICARE ADVAN-
TAGE AND PART D PLANS. 
(a) IN GENERAL.—Section 1857(g)(2)(A) of the So-
cial Security Act (42 U.S.C. 1395w–27(g)(2)(A)) is 
amended by inserting ‘‘except with respect to a determina-
tion under subparagraph (E), an assessment of not more 
than 3 times the amount claimed by such plan or plan 
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sponsor based upon the misrepresentation or falsified in-
formation involved,’’ after ‘‘for each such determination,’’. 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) shall apply to violations committed on or 
after January 1, 2010. 
SEC. 1617. ENHANCED PENALTIES FOR MEDICARE ADVAN-
TAGE AND PART D MARKETING VIOLATIONS. 
(a) IN GENERAL.—Section 1857(g)(1) of the Social 
Security Act (42 U.S.C. 1395w–27(g)(1)), as amended by 
section 1221(b), is amended— 
(1) in subparagraph (G), by striking ‘‘or’’ at 
the end; 
(2) by inserting after subparagraph (H) the fol-
lowing new subparagraphs: 
‘‘(I) except as provided under subpara-
graph (C) or (D) of section 1860D–1(b)(1), en-
rolls an individual in any plan under this part 
without the prior consent of the individual or 
the designee of the individual; 
‘‘(J) transfers an individual enrolled under 
this part from one plan to another without the 
prior consent of the individual or the designee 
of the individual or solely for the purpose of 
earning a commission; 
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‘‘(K) fails to comply with marketing re-
strictions described in subsections (h) and (j) of 
section 1851 or applicable implementing regula-
tions or guidance; or 
‘‘(L) employs or contracts with any indi-
vidual or entity who engages in the conduct de-
scribed in subparagraphs (A) through (K) of 
this paragraph;’’; and 
(3) by adding at the end the following new sen-
tence: ‘‘The Secretary may provide, in addition to 
any other remedies authorized by law, for any of the 
remedies described in paragraph (2), if the Secretary 
determines that any employee or agent of such orga-
nization, or any provider or supplier who contracts 
with such organization, has engaged in any conduct 
described in subparagraphs (A) through (L) of this 
paragraph.’’ 
(b) EFFECTIVE DATE.—The amendments made by 
subsection (a) shall apply to violations committed on or 
after January 1, 2010. 
SEC. 1618. ENHANCED PENALTIES FOR OBSTRUCTION OF 
PROGRAM AUDITS. 
(a) IN GENERAL.—Section 1128(b)(2) of the Social 
Security Act (42 U.S.C. 1320a–7(b)(2)) is amended— 
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(1) in the heading, by inserting ‘‘OR AUDIT’’ 
after ‘‘INVESTIGATION’’; and 
(2) by striking ‘‘investigation into’’ and all that 
follows through the period and inserting ‘‘investiga-
tion or audit related to—’’ 
‘‘(i) any offense described in para-
graph (1) or in subsection (a); or 
‘‘(ii) the use of funds received, directly 
or indirectly, from any Federal health care 
program 
(as 
defined 
in 
section 
1128B(f)).’’. 
(b) EFFECTIVE DATE.—The amendments made by 
subsection (a) shall apply to violations committed on or 
after January 1, 2010. 
SEC. 1619. EXCLUSION OF CERTAIN INDIVIDUALS AND EN-
TITIES FROM PARTICIPATION IN MEDICARE 
AND STATE HEALTH CARE PROGRAMS. 
(a) IN GENERAL.—Section 1128(c) of the Social Se-
curity Act, as previously amended by this subdivision, is 
further amended— 
(1) in the heading, by striking ‘‘AND PERIOD’’ 
and inserting ‘‘, PERIOD, AND EFFECT’’; and 
(2) by adding at the end the following new 
paragraph: 
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‘‘(4)(A) For purposes of this Act, subject to 
subparagraph (C), the effect of exclusion is that no 
payment may be made by any Federal health care 
program (as defined in section 1128B(f)) with re-
spect to any item or service furnished— 
‘‘(i) by an excluded individual or entity; or 
‘‘(ii) at the medical direction or on the pre-
scription of a physician or other authorized in-
dividual when the person submitting a claim for 
such item or service knew or had reason to 
know of the exclusion of such individual. 
‘‘(B) For purposes of this section and sections 
1128A and 1128B, subject to subparagraph (C), an 
item or service has been furnished by an individual 
or entity if the individual or entity directly or indi-
rectly provided, ordered, manufactured, distributed, 
prescribed, or otherwise supplied the item or service 
regardless of how the item or service was paid for 
by a Federal health care program or to whom such 
payment was made. 
‘‘(C)(i) Payment may be made under a Federal 
health care program for emergency items or services 
(not including items or services furnished in an 
emergency room of a hospital) furnished by an ex-
cluded individual or entity, or at the medical direc-
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tion or on the prescription of an excluded physician 
or other authorized individual during the period of 
such individual’s exclusion. 
‘‘(ii) In the case that an individual eligible for 
benefits under title XVIII or XIX submits a claim 
for payment for items or services furnished by an ex-
cluded individual or entity, and such individual eligi-
ble for such benefits did not know or have reason to 
know that such excluded individual or entity was so 
excluded, then, notwithstanding such exclusion, pay-
ment shall be made for such items or services. In 
such case the Secretary shall notify such individual 
eligible for such benefits of the exclusion of the indi-
vidual or entity furnishing the items or services. 
Payment shall not be made for items or services fur-
nished by an excluded individual or entity to an indi-
vidual eligible for such benefits after a reasonable 
time (as determined by the Secretary in regulations) 
after the Secretary has notified the individual eligi-
ble for such benefits of the exclusion of the indi-
vidual or entity furnishing the items or services. 
‘‘(iii) In the case that a claim for payment for 
items or services furnished by an excluded individual 
or entity is submitted by an individual or entity 
other than an individual eligible for benefits under 
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the association, committee, joint board of trust-
ees, or other similar group of representatives of 
the parties who establish or maintain the plan, 
or 
‘‘(D) the cooperative or association de-
scribed in subsection (c)(2)(F) in the case of a 
plan established or maintained by such a coop-
erative or association. 
‘‘(c) APPLICABLE SELF-INSURED HEALTH PLAN.— 
For purposes of this section, the term ‘applicable self-in-
sured health plan’ means any plan for providing accident 
or health coverage if— 
‘‘(1) any portion of such coverage is provided 
other than through an insurance policy, and 
‘‘(2) such plan is established or maintained— 
‘‘(A) by one or more employers for the 
benefit of their employees or former employees, 
‘‘(B) by one or more employee organiza-
tions for the benefit of their members or former 
members, 
‘‘(C) jointly by 1 or more employers and 1 
or more employee organizations for the benefit 
of employees or former employees, 
‘‘(D) by a voluntary employees’ beneficiary 
association described in section 501(c)(9), 
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ported by a grant made to the State under this sec-
tion, the outcomes the programs are intended to 
achieve, and the evidence supporting the effective-
ness of the programs. 
‘‘(2) RESULTS OF NEEDS ASSESSMENT.—The 
results of a statewide needs assessment that de-
scribes— 
‘‘(A) the number, quality, and capacity of 
home visitation programs for families with 
young children and families expecting children 
in the State; 
‘‘(B) the number and types of families who 
are receiving services under the programs; 
‘‘(C) the sources and amount of funding 
provided to the programs; 
‘‘(D) the gaps in home visitation in the 
State, including identification of communities 
that are in high need of the services; and 
‘‘(E) training and technical assistance ac-
tivities designed to achieve or support the goals 
of the programs. 
‘‘(3) ASSURANCES.—Assurances from the State 
that— 
‘‘(A) in supporting home visitation pro-
grams using funds provided under this section, 
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