539 
extent practicable, such Form or such informa-
tion to meet the requirements of paragraph (1) 
and to be submitted in a manner specified by 
the Secretary. 
‘‘(C) SPECIAL
RULE.—In applying sub-
paragraph (A)(i)— 
‘‘(i) with respect to subsections (a) 
and (b), ‘ownership or control interest’ 
shall include direct or indirect interests, in-
cluding such interests in intermediate enti-
ties; and 
‘‘(ii) subsection (a)(3)(A)(ii) shall in-
clude the owner of a whole or part interest 
in any mortgage, deed of trust, note, or 
other obligation secured, in whole or in 
part, by the entity or any of the property 
or assets thereof, if the interest is equal to 
or exceeds 5 percent of the total property 
or assets of the entirety. 
‘‘(4) REPORTING.— 
‘‘(A) IN
GENERAL.—Not later than the 
date that is 2 years after the date of the enact-
ment of this subsection, the Secretary shall pro-
mulgate regulations requiring, effective on the 
date that is 90 days after the date on which 
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540 
such final regulations are published in the Fed-
eral Register, a facility to report the informa-
tion described in paragraph (3) to the Secretary 
in a standardized format, and such other regu-
lations as are necessary to carry out this sub-
section. Such final regulations shall ensure that 
the facility certifies, as a condition of participa-
tion and payment under the program under 
title XVIII or XIX, that the information re-
ported by the facility in accordance with such 
final regulations is accurate and current. 
‘‘(B) GUIDANCE.—The Secretary shall pro-
vide guidance and technical assistance to States 
on how to adopt the standardized format under 
subparagraph (A). 
‘‘(5) NO EFFECT ON EXISTING REPORTING RE-
QUIREMENTS.—Nothing in this subsection shall re-
duce, diminish, or alter any reporting requirement 
for a facility that is in effect as of the date of the 
enactment of this subsection. 
‘‘(6) DEFINITIONS.—In this subsection: 
‘‘(A) ADDITIONAL DISCLOSABLE PARTY.— 
The term ‘additional disclosable party’ means, 
with respect to a facility, any person or entity 
who— 
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541 
‘‘(i) exercises operational, financial, or 
managerial control over the facility or a 
part thereof, or provides policies or proce-
dures for any of the operations of the facil-
ity, or provides financial or cash manage-
ment services to the facility; 
‘‘(ii) leases or subleases real property 
to the facility, or owns a whole or part in-
terest equal to or exceeding 5 percent of 
the total value of such real property; 
‘‘(iii) lends funds or provides a finan-
cial guarantee to the facility in an amount 
which is equal to or exceeds $50,000; or 
‘‘(iv) provides management or admin-
istrative services, clinical consulting serv-
ices, or accounting or financial services to 
the facility. 
‘‘(B) FACILITY.—The term ‘facility’ means 
a disclosing entity which is— 
‘‘(i) a skilled nursing facility (as de-
fined in section 1819(a)); or 
‘‘(ii) a nursing facility (as defined in 
section 1919(a)). 
‘‘(C) MANAGING
EMPLOYEE.—The term 
‘managing employee’ means, with respect to a 
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542 
facility, an individual (including a general man-
ager, business manager, administrator, director, 
or consultant) who directly or indirectly man-
ages, advises, or supervises any element of the 
practices, finances, or operations of the facility. 
‘‘(D) ORGANIZATIONAL STRUCTURE.—The 
term ‘organizational structure’ means, in the 
case of— 
‘‘(i) a corporation, the officers, direc-
tors, and shareholders of the corporation 
who have an ownership interest in the cor-
poration which is equal to or exceeds 5 
percent; 
‘‘(ii) a limited liability company, the 
members and managers of the limited li-
ability company (including, as applicable, 
what percentage each member and man-
ager has of the ownership interest in the 
limited liability company); 
‘‘(iii) a general partnership, the part-
ners of the general partnership; 
‘‘(iv) a limited partnership, the gen-
eral partners and any limited partners of 
the limited partnership who have an own-
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543 
ership interest in the limited partnership 
which is equal to or exceeds 10 percent; 
‘‘(v) a trust, the trustees of the trust; 
‘‘(vi) an individual, contact informa-
tion for the individual; and 
‘‘(vii) any other person or entity, such 
information as the Secretary determines 
appropriate.’’. 
(b) PUBLIC AVAILABILITY OF INFORMATION.— 
(1) IN GENERAL.—Not later than the date that 
is 1 year after the date on which the final regula-
tions promulgated under section 1124(c)(4)(A) of 
the Social Security Act, as added by subsection (a), 
are published in the Federal Register, the informa-
tion reported in accordance with such final regula-
tions shall be made available to the public in accord-
ance with procedures established by the Secretary. 
(2) 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. 
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544 
(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)). 
(c) CONFORMING AMENDMENTS.— 
(1) SKILLED
NURSING
FACILITIES.—Section 
1819(d)(1) of the Social Security Act (42 U.S.C. 
1395i–3(d)(1)) is amended by striking subparagraph 
(B) and redesignating subparagraph (C) as subpara-
graph (B). 
(2) NURSING FACILITIES.—Section 1919(d)(1) 
of the Social Security Act (42 U.S.C. 1396r(d)(1)) 
is amended by striking subparagraph (B) and redes-
ignating subparagraph (C) as subparagraph (B). 
SEC. 1412. ACCOUNTABILITY REQUIREMENTS. 
(a) EFFECTIVE COMPLIANCE
AND ETHICS PRO-
GRAMS.— 
(1) SKILLED
NURSING
FACILITIES.—Section 
1819(d)(1) of the Social Security Act (42 U.S.C. 
1395i–3(d)(1)), as amended by section 1411(c)(1), 
is amended by adding at the end the following new 
subparagraph: 
‘‘(C) COMPLIANCE
AND
ETHICS
PRO-
GRAMS.— 
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may include a model compliance pro-
gram. 
‘‘(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 shall 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 evaluation of the compliance and 
ethics programs required to be estab-
lished under this subparagraph. Such 
evaluation shall determine if such pro-
grams led to changes in deficiency ci-
tations, changes in quality perform-
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547 
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 
skilled nursing facility, a program of the 
operating 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 
under this Act and in promoting qual-
ity of care; and 
‘‘(II) includes at least the re-
quired components specified in clause 
(iv). 
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548 
‘‘(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, contractors, and other agents 
that are reasonably capable of reduc-
ing the prospect of criminal, civil, and 
administrative 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 have sufficient resources and au-
thority to assure such compliance. 
‘‘(III) The organization must 
have used due care not to delegate 
substantial discretionary authority to 
individuals whom the organization 
knew, or should have known through 
the exercise of due diligence, had a 
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549 
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 
agents could report violations by oth-
ers within the organization without 
fear of retribution. 
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550 
‘‘(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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551 
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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552 
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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553 
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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554 
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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555 
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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556 
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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557 
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 skilled nursing facility’’ as a clause (i) 
with the heading ‘‘IN GENERAL.—’’ and the ap-
propriate indentation; 
(C) in clause (i) (as so designated by sub-
paragraph (B)), by redesignating clauses (i) 
and (ii) as subclauses (I) and (II), respectively; 
and 
(D) by adding at the end the following new 
clause: 
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558 
‘‘(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 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 
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559 
quality assessment and assurance ac-
tivities conducted under clause (i). 
‘‘(II) REGULATIONS.—The Sec-
retary shall promulgate regulations to 
carry out this clause.’’. 
(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’) 
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560 
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 
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-
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dcolon on DSK2BSOYB1PROD with BILLS
561 
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 
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.— 
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562 
(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-
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.— 
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563 
(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: 
‘‘(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 
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564 
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 
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-
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565 
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 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 
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566 
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-
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 
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567 
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. 
‘‘(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.— 
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568 
‘‘(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; and 
‘‘(iv) any other representatives of pro-
grams or groups the Secretary determines 
appropriate.’’. 
(2) TIMELINESS
OF
SUBMISSION
OF
SURVEY 
AND CERTIFICATION INFORMATION.— 
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569 
(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-
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. 
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570 
(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-
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.— 
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571 
‘‘(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) 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— 
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572 
‘‘(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); 
‘‘(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), 
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573 
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. 
‘‘(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 
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574 
(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 
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). 
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575 
‘‘(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; 
‘‘(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 
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576 
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 
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. 
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577 
‘‘(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. 
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.’’. 
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578 
(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— 
‘‘(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.— 
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(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 
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-
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580 
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;’’. 
(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: 
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581 
‘‘(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-
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-
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582 
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). 
‘‘(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 
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583 
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- 
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 
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584 
‘‘(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-
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, 
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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; 
‘‘(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-
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586 
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 
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 retali-
ated against or had a contract for services 
terminated in violation of clause (i) or 
against whom a complaint has been filed in 
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587 
violation 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 
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. 
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588 
‘‘(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 
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— 
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589 
‘‘(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 
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.— 
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590 
‘‘(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. 
‘‘(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 
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591 
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-
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. 
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592 
‘‘(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 
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). 
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593 
‘‘(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 
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-
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594 
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 
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). 
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595 
‘‘(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.’’. 
(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-
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596 
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 
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 
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597 
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.’’. 
(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 
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598 
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 
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-
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599 
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.’’. 
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 
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600 
‘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. 
‘‘(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 
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601 
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-
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. 
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602 
‘‘(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 
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. 
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603 
‘‘(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 
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 
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605 
‘‘(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 
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 
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606 
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).’’. 
(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 
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607 
(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). 
‘‘(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 
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608 
‘‘(III) in each case of any other 
deficiency, an amount not less than 
$250 and not to exceed $3050. 
‘‘(iii) 
APPLICABLE
PER
DAY 
AMOUNT.—In this subparagraph, the term 
‘applicable per day amount’ means— 
‘‘(I) in each case of a 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 
‘‘(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. 
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609 
‘‘(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 
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 
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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. 
‘‘(vi) 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-
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-
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611 
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-
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 
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dcolon on DSK2BSOYB1PROD with BILLS
612 
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 
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)’’. 
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613 
(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 
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 
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614 
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 
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 
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615 
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 
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; 
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616 
‘‘(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 
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-
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617 
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 
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. 
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623 
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 
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, 
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655 
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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797 
Subtitle D—Coverage 
SEC. 1731. OPTIONAL MEDICAID COVERAGE OF LOW-IN-
COME HIV-INFECTED INDIVIDUALS. 
(a) IN GENERAL.—Section 1902 of the Social Secu-
rity Act (42 U.S.C. 1396a), as amended by section 
1714(a)(1), is amended— 
(1) in subsection (a)(10)(A)(ii)— 
(A) by striking ‘‘or’’ at the end of sub-
clause (XIX); 
(B) by adding ‘‘or’’ at the end of subclause 
(XX); and 
(C) by adding at the end the following: 
‘‘(XXI) who are described in subsection (ii) (re-
lating to HIV-infected individuals);’’; and 
(2) by adding at the end, as amended by sec-
tions 1703 and 1714(a), the following: 
‘‘(ii) individuals described in this subsection are indi-
viduals not described in subsection (a)(10)(A)(i)— 
‘‘(1) who have HIV infection; 
‘‘(2) whose income (as determined under the 
State plan under this title with respect to disabled 
individuals) does not exceed the maximum amount 
of income a disabled individual described in sub-
section (a)(10)(A)(i) may have and obtain medical 
assistance under the plan; and 
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