II 116th CONGRESS 1st Session S. 2943 IN THE SENATE OF THE UNITED STATES November 21, 2019 Mr. Blumenthal (for himself, Ms. Klobuchar , and Mr. Booker ) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend titles XVIII and XIX of the Social Security Act to revise minimum nurse staffing requirements for skilled nursing facilities under the Medicare program and for nursing facilities under the Medicaid program, and for other purposes.

1. Short title This Act may be cited as the Quality Care for Nursing Home Residents Act of 2019 . 2. Minimum nurse staffing requirements for skilled nursing facilities under Medicare program and nursing facilities under Medicaid program (a) Medicare (1) In general Subparagraph (C) of section 1819(b)(4) of the Social Security Act ( 42 U.S.C. 1395i–3(b)(4) ) is amended— (A) in clause (i)— (i) by amending the clause heading to read as follows: General requirements before 2020 ; and (ii) by striking Except as provided in clause (ii), and inserting Except as provided in clause (iii), with respect to skilled nursing facility services provided before January 1, 2020, ; (B) by redesignating clause (ii) as clause (iii); and (C) by inserting after clause (i) the following new clause: (ii) General requirements after 2019 (I) In general With respect to skilled nursing facility services provided on or after January 1, 2020, a skilled nursing facility must— (aa) provide nursing services that are sufficient to meet the nursing needs of its residents on a 24-hour basis, to be divided into day shifts, evening shifts, and night shifts; (bb) provide for minimum nurse staffing levels with respect to each such shift, in accordance with this clause; and (cc) ensure that, in carrying out items (aa) and (bb), a total minimum of 4.1 hours of care is provided per resident per day, with 0.75 hours of care of such total minimum provided by a registered professional nurse, 0.54 hours of care of such total minimum provided by a licensed practical nurse, and 2.81 hours of care of such total minimum provided by a nurse aide (as defined in paragraph (5)(F)). (II) Day shifts With respect to a day shift, the skilled nursing facility must have— (aa) at least 1 registered professional nurse for every 28 residents, with a minimum of 0.29 hours of care provided per resident during each such shift; (bb) at least 1 licensed practical nurse for every 40 residents, with a minimum of 0.20 hours of care provided per resident during each such shift; and (cc) at least 1 nurse aide (as defined in paragraph (5)(F)) for every 7 residents, with a minimum of 1.14 hours of care provided per resident during each such shift. (III) Evening shifts With respect to an evening shift, the skilled nursing facility must have— (aa) at least 1 registered professional nurse for every 30 residents, with a minimum of 0.26 hours of care provided per resident during each such shift; (bb) at least 1 licensed practical nurse for every 40 residents, with a minimum of 0.20 hours of care provided per resident during each such shift; and (cc) at least 1 nurse aide (as defined in paragraph (5)(F)) for every 7 residents, with a minimum of 1.14 hours of care provided per resident during each such shift. (IV) Night shifts With respect to a night shift, the skilled nursing facility must have— (aa) at least 1 registered professional nurse for every 40 residents, with a minimum of 0.20 hours of care provided per resident during such shift; (bb) at least 1 licensed practical nurse for every 56 residents, with a minimum of 0.14 hours of care provided per resident during such shift; and (cc) at least 1 nurse aide (as defined in paragraph (5)(F)) for every 15 residents, with a minimum of 0.53 hours of care provided per resident during such shift. (V) Secretarial authority to establish higher minimum nurse staffing levels The Secretary may establish and require skilled nursing facilities (or, at the Secretary’s discretion, only skilled nursing facilities that have a higher percentage of residents with extensive care needs, as determined by the Secretary) to provide for minimum nurse staffing levels that are higher than the levels required under this clause. (VI) Rule of construction regarding State authority to establish higher minimum nurse staffing levels Nothing in this clause may be construed as preventing a State from establishing or requiring skilled nursing facilities in the State to provide for minimum nurse staffing levels that are higher than the levels required under this clause. (VII) Clarification with respect to minimum hours of care provided per resident requirements In complying with the minimum hours of care provided per resident requirements under this clause, a skilled nursing facility may not count any time spent by a registered professional nurse, licensed practical nurse, or nurse aide on administrative services towards compliance with such requirements. (VIII) Definitions In this clause: (aa) Administrative services The term administrative services means food preparation, housekeeping, laundry services, maintenance services, and other noncaregiving-related services, as determined by the Secretary. (bb) Day shift The term day shift means, with respect to a day and a skilled nursing facility, an assigned work shift that is a period of 8 consecutive hours, beginning not sooner than 6 a.m. in the time zone in which such facility is located and not later than 8 a.m. in such time zone. (cc) Evening shift The term evening shift means, with respect to a day and a skilled nursing facility, an assigned work shift that is a period of 8 consecutive hours, beginning not sooner than 2 p.m. in the time zone in which such facility is located and not later than 4 p.m. in such time zone. (dd) Night shift The term night shift means, with respect to a day and a skilled nursing facility, an assigned work shift that is a period of 8 consecutive hours, beginning not sooner than 10 p.m. in the time zone in which such facility is located and not later than midnight in such time zone. . (2) Enforcement Section 1819(h) of the Social Security Act ( 42 U.S.C. 1395i–3(h) ) is amended— (A) in paragraph (1), by striking If a State finds, on the basis of a standard and inserting Subject to paragraph (7), if a State finds, on the basis of a standard ; (B) in paragraph (2), by striking With respect to and inserting Subject to paragraph (7), with respect to ; and (C) by adding at the end the following new paragraph: (7) Special enforcement process with respect to minimum nurse staffing requirements (A) In general If a State finds, on the basis of a standard, extended, or partial extended survey under subsection (g)(2) or otherwise, that a skilled nursing facility does not meet the minimum staffing requirements of clause (ii) of subsection (b)(4)(C) with respect to skilled nursing facility services provided on or after January 1, 2020, the State shall recommend to the Secretary that the Secretary take such actions as described in subclauses (I) and (II) of subparagraph (B)(i). (B) Secretarial authority (i) In general With respect to any skilled nursing facility in a State, if the Secretary finds, or pursuant to a recommendation of the State under subparagraph (A) finds, that a skilled nursing facility does not meet the minimum staffing requirements of clause (ii) of subsection (b)(4)(C) with respect to skilled nursing facility services provided on or after January 1, 2020, the Secretary shall— (I) deny any further payments under this title with respect to all individuals entitled to benefits under this title who are admitted to the facility after the effective date of the finding; and (II) impose a civil money penalty in an amount not to exceed $10,000 for each day of noncompliance. The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a). (ii) Reduction of civil money penalties in certain circumstances Subject to clause (iii), in the case where a skilled nursing facility self-reports and promptly corrects a deficiency for which a penalty was imposed under clause (i)(II) not later than 10 calendar days after the date of such imposition, the Secretary may reduce the amount of the penalty imposed by— (I) not more than 50 percent; or (II) in the case that the facility was penalized under this subsection within the three-year period preceding the date of such imposition, not more than 25 percent. (iii) Prohibitions on reduction for certain deficiencies (I) Repeat deficiencies The Secretary may not reduce the amount of a penalty under clause (ii) if the Secretary had reduced a penalty imposed on the skilled nursing facility in the preceding year under such clause with respect to a repeat deficiency. (II) Certain other deficiencies The Secretary may not reduce the amount of a penalty under clause (ii) if the penalty is imposed on the skilled nursing facility for a deficiency that is found to result in a pattern of harm or widespread harm, immediately jeopardizes the health or safety of a resident or residents of the facility, or results in the death of a resident of the facility. (iv) Repeated noncompliance In the case of a skilled nursing facility which, on three consecutive standard surveys conducted under subsection (g)(2), has been found as not meeting the minimum staffing requirements of clause (ii) of subsection (b)(4)(C) with respect to skilled nursing facility services provided on or after January 1, 2020, the Secretary may (regardless of the remedies provided for under clause (i))— (I) appoint temporary management to oversee the operation of the facility and to assure the health and safety of the facility’s residents in accordance with clause (iii) of paragraph (2)(B), except that the minimum staffing requirements of clause (ii) of subsection (b)(4)(C) shall be substituted for all the requirements of subsections (b), (c), and (d) under such clause; (II) monitor the facility under subsection (g)(4)(B) with respect to such minimum staffing requirements until the facility has demonstrated to the satisfaction of the Secretary that the facility is in compliance, and will remain in compliance, with such minimum staffing requirements; or (III) subject to section 1128I(h), terminate the facility’s participation under this title. If the facility’s participation under this title is terminated under this clause, the State shall provide for the safe and orderly transfer of the residents eligible under this title, consistent with the requirements of subsection (c)(2) and section 1128I(h). (v) Public notice of violations (I) Internet website The Secretary shall publish on the internet website of the Department of Health and Human Services the names of skilled nursing facilities that have violated the minimum staffing requirements of clause (ii) of subsection (b)(4)(C) with respect to skilled nursing facility services provided on or after January 1, 2020. (II) Change of ownership With respect to a skilled nursing facility whose name is published under subclause (I) and has a change of ownership, as determined by the Secretary, after the date of such publication, the Secretary shall remove the name of such facility from the website described under such subclause after the 1-year period beginning on the date of such change of ownership. . (3) Conforming amendment Item (a) of section 1819(f)(2)(B)(iii)(I) of the Social Security Act ( 42 U.S.C. 1395i–3(f)(2)(B)(iii)(I) ) is amended by striking subsection (b)(4)(C)(ii)(II) and inserting subsection (b)(4)(C)(iii)(II) . (b) Medicaid (1) In general Subparagraph (C) of section 1919(b)(4) of the Social Security Act ( 42 U.S.C. 1396r(b)(4) ) is amended— (A) in clause (i)— (i) in the clause heading, by inserting after General requirements the following before 2020 ; (ii) in the matter preceding subclause (I), by inserting after October 1, 1990, the following: and before January 1, 2020, ; (iii) in subclause (I), by striking clause (ii) and inserting clause (iii) ; and (iv) in subclause (II), by striking clause (ii) and inserting clause (iii) ; (B) by redesignating clauses (ii) and (iii) as clauses (iii) and (iv), respectively; and (C) by inserting after clause (i) the following new clause: (ii) General requirements after 2019 (I) In general With respect to nursing facility services provided on or after January 1, 2020, a nursing facility must— (aa) provide nursing services that are sufficient to meet the nursing needs of its residents on a 24-hour basis, to be divided into day shifts, evening shifts, and night shifts; (bb) provide for minimum nurse staffing levels with respect to each such shift, in accordance with this clause; and (cc) ensure that, in carrying out items (aa) and (bb), a total minimum of 4.1 hours of care is provided per resident per day, with 0.75 hours of care of such total minimum provided by a registered professional nurse, 0.54 hours of care of such total minimum provided by a licensed practical nurse, and 2.81 hours of care of such total minimum provided by a nurse aide (as defined in paragraph (5)(F)). (II) Day shifts With respect to a day shift, the nursing facility must have— (aa) at least 1 registered professional nurse for every 28 residents, with a minimum of 0.29 hours of care provided per resident during each such shift; (bb) at least 1 licensed practical nurse for every 40 residents, with a minimum of 0.20 hours of care provided per resident during each such shift; and (cc) at least 1 nurse aide (as defined in paragraph (5)(F)) for every 7 residents, with a minimum of 1.14 hours of care provided per resident during each such shift. (III) Evening shifts With respect to an evening shift, the nursing facility must have— (aa) at least 1 registered professional nurse for every 30 residents, with a minimum of 0.26 hours of care provided per resident during each such shift; (bb) at least 1 licensed practical nurse for every 40 residents, with a minimum of 0.20 hours of care provided per resident during each such shift; and (cc) at least 1 nurse aide (as defined in paragraph (5)(F)) for every 7 residents, with a minimum of 1.14 hours of care provided per resident during each such shift. (IV) Night shifts With respect to a night shift, the nursing facility must have— (aa) at least 1 registered professional nurse for every 40 residents, with a minimum of 0.20 hours of care provided per resident during such shift; (bb) at least 1 licensed practical nurse for every 56 residents, with a minimum of 0.14 hours of care provided per resident during such shift; and (cc) at least 1 nurse aide (as defined in paragraph (5)(F)) for every 15 residents, with a minimum of 0.53 hours of care provided per resident during such shift. (V) Secretarial authority to establish higher minimum nurse staffing levels The Secretary may establish and require nursing facilities (or, at the Secretary’s discretion, only nursing facilities that have a higher percentage of residents with extensive care needs, as determined by the Secretary) to provide for minimum nurse staffing levels that are higher than the levels required under this clause. (VI) Rule of construction regarding State authority to establish higher minimum nurse staffing levels Nothing in this clause may be construed as preventing a State from establishing or requiring nursing facilities in the State to provide for minimum nurse staffing levels that are higher than the levels required under this clause. (VII) Clarification with respect to minimum hours of care provided per resident requirements In complying with the minimum hours of care provided per resident requirements under this clause, a nursing facility may not count any time spent by a registered professional nurse, licensed practical nurse, or nurse aide on administrative services towards compliance with such requirements. (VIII) Definitions In this clause: (aa) Administrative services The term administrative services means food preparation, housekeeping, laundry services, maintenance services, and other noncaregiving-related services, as determined by the Secretary. (bb) Day shift The term day shift means, with respect to a day and a nursing facility, an assigned work shift that is a period of 8 consecutive hours, beginning not sooner than 6 a.m. in the time zone in which such facility is located and not later than 8 a.m. in such time zone. (cc) Evening shift The term evening shift means, with respect to a day and a nursing facility, an assigned work shift that is a period of 8 consecutive hours, beginning not sooner than 2 p.m. in the time zone in which such facility is located and not later than 4 p.m. in such time zone. (dd) Night shift The term night shift means, with respect to a day and a nursing facility, an assigned work shift that is a period of 8 consecutive hours, beginning not sooner than 10 p.m. in the time zone in which such facility is located and not later than midnight in such time zone. . (2) Enforcement Section 1919(h) of the Social Security Act ( 42 U.S.C. 1396r(h) ) is amended— (A) in paragraph (1), by striking If a State finds, on the basis of a standard and inserting Subject to paragraph (10), if a State finds, on the basis of a standard ; (B) in paragraph (2)— (i) in subparagraph (C), by striking If a nursing facility and inserting Subject to paragraph (10), if a nursing facility ; and (ii) in subparagraph (D), by striking In the case of and inserting Subject to paragraph (10), in the case of ; (C) in paragraph (3)— (i) in subparagraph (A), by inserting before the period the following: and the remedies described in paragraph (10)(B) ; and (ii) in subparagraph (B), by striking With respect to and inserting Subject to paragraph (10), with respect to ; and (D) by adding at the end the following new paragraph: (10) Special enforcement process with respect to minimum nurse staffing requirements (A) In general If a State finds, on the basis of a standard, extended, or partial extended survey under subsection (g)(2) or otherwise, that a nursing facility does not meet the minimum staffing requirements of clause (ii) of subsection (b)(4)(C) with respect to nursing facility services provided on or after January 1, 2020, the State shall— (i) deny any further payments under the State plan with respect to all individuals enrolled under such plan who are admitted to the facility after the effective date of the finding; and (ii) recommend to the Secretary that the Secretary impose the civil money penalty described in subparagraph (B). (B) Secretarial authority (i) In general With respect to any nursing facility in a State other than a State nursing facility, if the Secretary finds that such a nursing facility does not meet the minimum staffing requirements of clause (ii) of subsection (b)(4)(C) with respect to nursing facility services provided on or after January 1, 2020, the Secretary shall— (I) deny any further payments to the State for medical assistance furnished by the facility to all individuals enrolled under the State plan who are admitted to the facility after the effective date of the finding; and (II) impose a civil money penalty in an amount not to exceed $10,000 for each day of noncompliance. The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a). (ii) Reduction of civil money penalties in certain circumstances Subject to clause (iii), in the case where a nursing facility self-reports and promptly corrects a deficiency for which a penalty was imposed under clause (i)(II) not later than 10 calendar days after the date of such imposition, the Secretary may reduce the amount of the penalty imposed by— (I) not more than 50 percent; or (II) in the case that the facility was penalized under this subsection within the three-year period preceding the date of such imposition, not more than 25 percent. (iii) Prohibitions on reduction for certain deficiencies (I) Repeat deficiencies The Secretary may not reduce the amount of a penalty under clause (ii) if the Secretary had reduced a penalty imposed on the nursing facility in the preceding year under such clause with respect to a repeat deficiency. (II) Certain other deficiencies The Secretary may not reduce the amount of a penalty under clause (ii) if the penalty is imposed on the nursing facility for a deficiency that is found to result in a pattern of harm or widespread harm, immediately jeopardizes the health or safety of a resident or residents of the facility, or results in the death of a resident of the facility. (iv) Repeated noncompliance In the case of a nursing facility which, on three consecutive standard surveys conducted under subsection (g)(2), has been found as not meeting the minimum staffing requirements of clause (ii) of subsection (b)(4)(C) with respect to nursing facility services provided on or after January 1, 2020, the Secretary may (regardless of the remedies provided for under clause (i))— (I) appoint temporary management to oversee the operation of the facility and to assure the health and safety of the facility’s residents in accordance with clause (iii) of paragraph (3)(C), except that the minimum staffing requirements of clause (ii) of subsection (b)(4)(C) shall be substituted for all the requirements of subsections (b), (c), and (d) under such clause; (II) monitor the facility under subsection (g)(4)(B) with respect to such minimum staffing requirements until the facility has demonstrated to the satisfaction of the Secretary that the facility is in compliance, and will remain in compliance, with such minimum staffing requirements; or (III) subject to section 1128I(h), terminate the facility’s participation under this title. If the facility’s participation under this title is terminated under this clause, the State shall provide for the safe and orderly transfer of the residents eligible under this title, consistent with the requirements of subsection (c)(2) and section 1128I(h). (v) Public notice of violations (I) Internet website The Secretary shall publish on the internet website of the Department of Health and Human Services the names of nursing facilities that have violated the minimum staffing requirements of clause (ii) of subsection (b)(4)(C) with respect to skilled nursing facility services provided on or after January 1, 2020. (II) Change of ownership With respect to a nursing facility whose name is published under subclause (I) and has a change of ownership, as determined by the Secretary, after the date of such publication, the Secretary shall remove the name of such facility from the website described under such subclause after the 1-year period beginning on the date of such change of ownership. . (3) Conforming amendments (A) Clause (iii) of section 1919(b)(4)(C) of the Social Security Act ( 42 U.S.C. 1396r(b)(4)(C) ), as redesignated by paragraph (1)(B), is amended by striking subject to clause (iii) and inserting subject to clause (iv) . (B) Item (a) of section 1919(f)(2)(B)(iii)(I) of the Social Security Act ( 42 U.S.C. 1396r(f)(2)(B)(iii)(I) ) is amended by striking subsection (b)(4)(C)(ii) and inserting subsection (b)(4)(C)(iii) . (C) Paragraph (9) of section 1919(f) of the Social Security Act ( 42 U.S.C. 1396r(f) ) is amended by striking subsection (b)(4)(C)(ii) and inserting subsection (b)(4)(C)(iii) . (c) Studies and reports regarding impact of minimum nurse staffing requirements (1) Initial study and report (A) In general Not later than June 1, 2021, the Secretary of Health and Human Services shall study and submit to the Committee on Energy and Commerce and the Committee on Ways and Means of the House of Representatives and the Committee on Finance of the Senate a publicly available report— (i) on the impact of the minimum nurse staffing requirements added by subsection (a) on the reimbursement levels of skilled nursing facilities under the Medicare program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq.) and the adequacy of personnel numbers in such skilled nursing facilities to meet such minimum nurse staffing requirements; (ii) on the impact of the minimum nurse staffing requirements added by subsection (b) on the reimbursement levels of nursing facilities under the Medicaid program under title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq.) and the adequacy of personnel numbers in such nursing facilities to meet such minimum nurse staffing requirements; and (iii) including recommendations on the steps that such skilled nursing facilities and nursing facilities can take to ensure that adequate personnel are available in such skilled nursing facilities and nursing facilities to meet the minimum nurse staffing requirements added by subsections (a) and (b) for such skilled nursing facilities and nursing facilities, respectively, including methods for attracting and retaining such personnel. (B) Considerations In conducting the study required under subparagraph (A), the Secretary of Health and Human Services shall take into consideration— (i) the benefits of any increase in nurse staffing levels, including with respect to workforce training and retention; (ii) any decrease in the rate of workplace injuries; (iii) any changes in medical care costs for residents of skilled nursing facilities and nursing facilities; (iv) any decrease in hospitalization rates for such residents; (v) any changes in personnel and administrative costs for skilled nursing facilities and nursing facilities; and (vi) any changes in recruiting and training costs. (2) Subsequent study and report Not later than January 1, 2023, the Secretary of Health and Human Services shall conduct a follow-up study to the study conducted under paragraph (1)(A) and submit to the Committee on Energy and Commerce and the Committee on Ways and Means of the House of Representatives and the Committee on Finance of the Senate a publicly available report on such follow-up study. 3. Disclosure of nurse staffing levels at skilled nursing facilities under Medicare program and nursing facilities under Medicaid program (a) Medicare Paragraph (8) of section 1819(b) of the Social Security Act ( 42 U.S.C. 1395i–3(b) ) is amended to read as follows: (8) Information on nurse staffing (A) In general Each day, a skilled nursing facility shall post for each shift notices with— (i) a description of the nurse staffing requirements applicable with respect to the facility and day under paragraph (4)(C); (ii) information on the number of registered professional nurses, licensed practical nurses, and nurse aides (as defined in paragraph (5)(F)) assigned to provide direct care services to residents in the facility during the shift, disaggregated by units in the facility; and (iii) a statement that the facility is required, upon request, to provide any nurse staffing information (as described in this subparagraph) of the facility from the preceding 12-month period. The information in such notices shall be written in a uniform manner, printed in an easily readable 14-point type font, and made available in appropriate languages, as determined by the Secretary. The skilled nursing facility shall make such notices available at each nurses station in the facility and other areas in each unit of the facility, as determined appropriate by the facility, and shall keep and maintain each such notice for at least three years after the date on which each such notice is posted in the facility. (B) Public availability of information A skilled nursing facility shall, upon request, make available to the public any nurse staffing information (as described in subparagraph (A)) of the facility from the preceding 12-month period. In the case that the facility makes such information available as a paper copy, such facility may not charge for such copy an amount greater than the cost of making such copy. . (b) Medicaid Paragraph (8) of section 1919(b) of the Social Security Act ( 42 U.S.C. 1396r(b) ) is amended to read as follows: (8) Information on nurse staffing (A) In general Each day, a skilled nursing facility shall post for each shift notices with— (i) a description of the nurse staffing requirements applicable with respect to the facility and day under paragraph (4)(C); (ii) information on the number of registered professional nurses, licensed practical nurses, and nurse aides (as defined in paragraph (5)(F)) assigned to provide direct care services to residents in the facility during the shift, disaggregated by units in the facility; and (iii) a statement that the facility is required, upon request, to provide any nurse staffing information (as described in this subparagraph) of the facility from the preceding 12-month period. The information in such notices shall be written in a uniform manner, printed in an easily readable 14-point type font, and made available in appropriate languages, as determined by the Secretary. The skilled nursing facility shall make such notices available at each nurses station in the facility and other areas in each unit of the facility, as determined appropriate by the facility, and shall keep and maintain each such notice for at least three years after the date on which each such notice is posted in the facility. (B) Public availability of information A skilled nursing facility shall, upon request, make available to the public any nurse staffing information (as described in subparagraph (A)) of the facility from the preceding 12-month period. . (c) Effective date The amendments made by this section take effect on the date of enactment of this Act and apply with respect to nurse staffing information posted or requested on or after the date that is one year after such date of enactment. 4. Administrative staffing requirements for skilled nursing facilities under Medicare program and nursing facilities under Medicaid program (a) Medicare Paragraph (1) of section 1819(d) of the Social Security Act ( 42 U.S.C. 1395i–3(d) ) is amended— (1) by redesignating the second subparagraph (C) as subparagraph (E); and (2) by inserting after the first subparagraph (C) the following new subparagraph: (D) Nursing management personnel (i) In general A skilled nursing facility must employ nursing management personnel in accordance with this subparagraph. (ii) Director of nursing services A skilled nursing facility must employ a registered professional nurse to serve full-time as the director of nursing services of the facility. Such director of nursing services shall be responsible for determining the number and types of nursing personnel needed to sufficiently meet the nursing needs of the residents of the facility (as required under subsection (b)(4)(C)). (iii) Assistant director of nursing services A skilled nursing facility must employ a registered professional nurse to serve full-time as the assistant director of nursing services of the facility, except that in the case of a skilled nursing facility that has fewer than 100 beds, such facility may employ a registered professional nurse to serve part-time as the assistant director of nursing services of the facility. A registered professional nurse who serves as the assistant director of nursing services of a skilled nursing facility may also serve as a supervisor for direct clinical nursing care for such facility. (iv) Director of in-Service education A skilled nursing facility must employ a registered professional nurse to serve full-time as the director of in-service education of the facility, except that in the case of a skilled nursing facility that has fewer than 100 beds, such facility may employ a registered professional nurse to serve part-time as the director of in-service education of the facility. In carrying out the previous sentence, a skilled nursing facility must, to the extent practicable and appropriate, employ a registered professional nurse who has received training in adult education and gerontology. . (b) Medicaid (1) In general Paragraph (1) of section 1919(d) of the Social Security Act ( 42 U.S.C. 1396r(d) ) is amended by inserting after subparagraph (C) the following new subparagraph: (D) Nursing management personnel (i) In general A nursing facility must employ nursing management personnel in accordance with this subparagraph. (ii) Director of nursing services A nursing facility must employ a registered professional nurse to serve full-time as the director of nursing services of the facility. Such director of nursing services shall be responsible for determining the number and types of nursing personnel needed to sufficiently meet the nursing needs of the residents of the facility (as required under subsection (b)(4)(C)). (iii) Assistant director of nursing services A nursing facility must employ a registered professional nurse to serve full-time as the assistant director of nursing services of the facility, except that in the case of a nursing facility that has fewer than 100 beds, such facility may employ a registered professional nurse to serve part-time as the assistant director of nursing services of the facility. A registered professional nurse who serves as the assistant director of nursing services of a nursing facility may also serve as a supervisor for direct clinical nursing care for such facility. (iv) Director of in-Service education A nursing facility must employ a registered professional nurse to serve full-time as the director of in-service education of the facility, except that in the case of a nursing facility that has fewer than 100 beds, such facility may employ a registered professional nurse to serve part-time as the director of in-service education of the facility. In carrying out the previous sentence, a nursing facility must, to the extent practicable and appropriate, employ a registered professional nurse who has received training in adult education and gerontology. . (2) Technical amendment Paragraph (1) of section 1919(d) of the Social Security Act ( 42 U.S.C. 1396r(d) ) is amended by redesignating subparagraph (V) as subparagraph (E). (c) Effective date The amendments made by this section take effect on the date of enactment of this Act and apply with respect to the administration of skilled nursing facilities and nursing facilities on or after the date that is one year after such date of enactment. 5. Nurse training requirements with respect to skilled nursing facilities under Medicare program and nursing facilities under Medicaid program (a) Medicare (1) Orientation for registered professional nurses, licensed practical nurses, and nurse aides Section 1819(d) of the Social Security Act ( 42 U.S.C. 1395i–3(d) ) is amended by adding at the end the following new paragraph: (5) Orientations A skilled nursing facility must provide to registered professional nurses, licensed practical nurses, and nurse aides, before such registered professional nurses, licensed practical nurses, and nurse aides are assigned to provide direct care services to residents in the facility, orientations providing education on the policies and emergency procedures of the facility and on residents’ rights under this section. . (2) Requirements for nurse aide training and competency evaluation programs and for nurse aide competency evaluation programs Subparagraph (A) of section 1819(f)(2) of the Social Security Act ( 42 U.S.C. 1395i–3(f)(2) ) is amended— (A) in the matter preceding clause (i), by inserting after 1988 the following: , and update, as determined necessary by the Secretary ; (B) in clause (i)— (i) by inserting after care of cognitively impaired residents, the following: care of older adults, ; (ii) by striking patient abuse prevention training, and inserting patient abuse prevention training), ; and (iii) by striking 75 hours and inserting 120 hours ; and (C) in clause (ii)— (i) by striking requirement relating to and inserting requirements relating to (I) ; (ii) by inserting after care of cognitively impaired residents, the following: care of older adults, ; and (iii) by striking and procedures and inserting (II) minimum hours of initial and ongoing training and retraining (including not less than 120 hours in the case of initial training), and (III) procedures . (b) Medicaid (1) Orientation for registered professional nurses, licensed practical nurses, and nurse aides Section 1919(d) of the Social Security Act ( 42 U.S.C. 1396r(d) ) is amended by adding at the end the following new paragraph: (5) Orientations A nursing facility must provide to registered professional nurses, licensed practical nurses, and nurse aides, before such registered professional nurses, licensed practical nurses, and nurse aides are assigned to provide direct care services to residents in the facility, orientations providing education on the policies and emergency procedures of the facility and on residents’ rights under this section. . (2) Requirements for nurse aide training and competency evaluation programs and for nurse aide competency evaluation programs Subparagraph (A) of section 1919(f)(2) of the Social Security Act ( 42 U.S.C. 1396r(f)(2) ) is amended— (A) in the matter preceding clause (i), by inserting after 1988 the following: , and update, as determined necessary by the Secretary ; (B) in clause (i)— (i) by inserting after care of cognitively impaired residents, the following: care of older adults, ; (ii) by striking patient abuse prevention training, and inserting patient abuse prevention training), ; and (iii) by striking 75 hours and inserting 120 hours ; and (C) in clause (ii)— (i) by striking requirement relating to and inserting requirements relating to (I) ; (ii) by inserting after care of cognitively impaired residents, the following: care of older adults, ; and (iii) by striking and procedures and inserting (II) minimum hours of initial and ongoing training and retraining (including not less than 120 hours in the case of initial training), and (III) procedures . (c) Effective date The amendments made by this section take effect on the date of enactment of this Act and shall apply with respect to nurse aide training and competency evaluation programs, nurse aide competency evaluation programs, and nurse orientations conducted on or after the date that is one year after such date of enactment. 6. Whistleblower and resident protections (a) Medicare Section 1819 of the Social Security Act ( 42 U.S.C. 1395i–3 ) is amended by adding at the end the following new subsection: (k) Whistleblower and resident protections (1) Statement regarding professional obligation and rights All nurses employed by a skilled nursing facility have a duty and right to act based on their professional judgment in accordance with the nursing laws and regulations of the State in which such facility is located, to provide nursing care in the exclusive interests of the residents of the facility, and to act as the residents’ advocate. (2) Objection to or refusal of work assignment A nurse may object to, or refuse to participate in, any activity, policy, practice, assignment, or task (referred to in this subsection as a work assignment ) if— (A) the nurse reasonably believes such work assignment to be in violation of the minimum nurse staffing requirements of clause (ii) of subsection (b)(4)(C); or (B) the nurse reasonably believes that the nurse is not prepared by education, training, or experience to perform or comply with such work assignment without compromising the safety of a resident or jeopardizing the license of the nurse. (3) Retaliation for objection to or refusal of work assignment barred (A) No discharge, discrimination, or retaliation No skilled nursing facility may discharge, retaliate, discriminate, or otherwise take adverse action in any manner with respect to any aspect of a nurse’s employment with the facility, including discharge, promotion, compensation, or terms, conditions, or privileges of employment, based on the nurse’s objection to, or refusal of, a work assignment under paragraph (2). (B) No filing of complaint No skilled nursing facility may file a complaint or a report against a nurse with a State professional disciplinary agency because of the nurse’s objection to, or refusal of, a work assignment under paragraph (2). (4) Cause of action Any nurse (or a collective bargaining representative or legal representative of such nurse) against whom a skilled nursing facility has taken an adverse action in violation of paragraph (3)(A), or against whom such facility has filed a complaint or report in violation of paragraph (3)(B), may (without regard to whether a complaint has been filed under paragraph (5) or (10)(B)) bring a cause of action in an appropriate district court of the United States. The legal burdens of proof specified in section 1221(e) of title 5, United States Code, shall be controlling for the purposes of any cause of action brought under this paragraph. A nurse who prevails on the cause of action may be entitled to one or more of the following: (A) Reinstatement. (B) Reimbursement of lost wages, compensation, and benefits. (C) Attorneys’ fees. (D) Court costs. (E) Other damages. (5) Complaint to Secretary Any individual may file a complaint with the Secretary against a skilled nursing facility that violates a requirement described in paragraph (3). For any complaint filed, the Secretary shall— (A) receive and investigate the complaint; (B) determine whether a violation of such paragraph, as alleged in the complaint, has occurred; and (C) in the case that the Secretary determines that such a violation has occurred, issue an order that the complaining individual may not suffer any adverse action prohibited by paragraph (3) or (7). (6) Toll-Free telephone number (A) In general The Secretary shall provide for the establishment of a toll-free telephone hotline to provide information regarding the minimum nurse staffing requirements of clause (ii) of subsection (b)(4)(C) and to receive reports of violations of such requirements. (B) Notice to residents A skilled nursing facility shall provide each resident admitted to the facility with the telephone number of the hotline described in subparagraph (A) and give notice to each such resident that such hotline may be used to report inadequate staffing. (7) Protection for reporting (A) Prohibition on retaliation or discrimination A skilled nursing facility may not retaliate or discriminate in any manner against any resident, employee, or contract employee of the facility, or any other individual, on the basis that such resident, employee, contract employee, or individual (individually or in conjunction with another individual) has, in good faith— (i) presented a grievance or complaint; (ii) initiated or cooperated in any investigation or proceeding of any governmental entity, regulatory agency, or private accreditation body; (iii) made a civil claim or demand; or (iv) filed an action relating to the care, services, or conditions of the facility. (B) Good faith defined For purposes of this paragraph, an individual shall be deemed to be acting in good faith if the individual reasonably believes— (i) the information reported or disclosed is true; and (ii) a violation of the minimum nurse staffing requirements of clause (ii) of subsection (b)(4)(C) has occurred or may occur. (8) Prohibition on interference with rights (A) Exercise of rights A skilled nursing facility may not— (i) interfere with, restrain, or deny the exercise, or attempt to exercise, by any individual of any right, procedure, or remedy provided or protected under this subsection; or (ii) coerce or intimidate any individual regarding the exercise, or attempt to exercise, such right. (B) Opposition to unlawful policies or practices A skilled nursing facility may not retaliate or discriminate against any individual for opposing any policy, practice, or action of the facility which is alleged to violate, breach, or fail to comply with any provision of the minimum nurse staffing requirements of clause (ii) of subsection (b)(4)(C). (C) Prohibition on interference with protected communications A skilled nursing facility may not make, adopt, or enforce any rule, regulation, policy, or practice which in any manner directly or indirectly prohibits, impedes, or discourages a nurse from, or intimidates, coerces, or induces a nurse regarding, engaging in free speech activities or disclosing information as provided under this subsection. (D) Prohibition on interference with collective action A skilled nursing facility may not in any way interfere with the rights of nurses to organize, bargain collectively, and engage in concerted activity under section 7 of the National Labor Relations Act ( 29 U.S.C. 157 ). (9) Notice A skilled nursing facility shall post in an appropriate location in each unit a conspicuous notice, in a form specified by the Secretary, that— (A) explains the rights of nurses, residents, and other individuals under this subsection; (B) includes a statement that a nurse, resident, or other individual may file a complaint with the Secretary against the facility for a violation of a requirement or a prohibition of this subsection; and (C) provides instructions on how to file such a complaint. (10) Enforcement (A) In general The Secretary shall enforce the requirements and prohibitions of this subsection in accordance with this paragraph. (B) Procedures for receiving and investigating complaints The Secretary shall establish procedures under which— (i) any individual may file a complaint alleging that a skilled nursing facility has violated a requirement or a prohibition of this subsection; and (ii) any such complaint shall be investigated by the Secretary. (C) Remedies If the Secretary determines that a skilled nursing facility has violated a requirement or prohibition of this subsection, the Secretary— (i) shall require the facility to establish a corrective action plan to prevent the recurrence of such violation; and (ii) may impose civil money penalties as described in subparagraph (D). (D) Civil penalties (i) In general In addition to any other penalties prescribed by law, the Secretary may impose civil penalties as follows: (I) Skilled nursing facility liability The Secretary may impose on a skilled nursing facility found to be in violation of this subsection a civil money penalty of— (aa) not more than $25,000 for the first knowing violation of this subsection by such facility; and (bb) not more than $50,000 for any subsequent knowing violation of this subsection by such facility. (II) Individual liability The Secretary may impose on an individual who— (aa) is employed by a skilled nursing facility; and (bb) is found by the Secretary to have knowingly violated this subsection on behalf of the facility, a civil money penalty of not more than $20,000 for each such violation by the individual. (ii) Procedures The provisions of section 1128A of the Social Security Act (other than subsections (a) and (b)) shall apply with respect to a civil money penalty or proceeding under this subparagraph in the same manner as such provisions apply with respect to a civil money penalty or proceeding under such section 1128A. (E) Public notice of violations (i) Internet website The Secretary shall publish on the internet website of the Department of Health and Human Services the names of skilled nursing facilities on which a civil money penalty has been imposed under this subsection, the violation for which such penalty was imposed, and such additional information as the Secretary determines appropriate. (ii) Change of ownership With respect to a skilled nursing facility that had a change of ownership, as determined by the Secretary, penalties imposed on the facility while under previous ownership shall no longer be published by the Secretary pursuant to clause (i) after the 1-year period beginning on the date of such change of ownership. (F) Use of funds Funds collected by the Secretary pursuant to this subsection are authorized to be appropriated to implement the minimum nurse staffing requirements of clause (ii) of subsection (b)(4)(C). (11) Nurse defined In this subsection, the term nurse means a registered professional nurse, a licensed practical nurse, and a nurse aide. . (b) Medicaid Section 1919 of the Social Security Act ( 42 U.S.C. 1396r ) is amended by adding at the end the following new subsection: (k) Whistleblower and resident protections (1) Statement regarding professional obligation and rights All nurses employed by a nursing facility have a duty and right to act based on their professional judgment in accordance with the nursing laws and regulations of the State in which such facility is located, to provide nursing care in the exclusive interests of the residents of the facility, and to act as the residents’ advocate. (2) Objection to or refusal of work assignment A nurse may object to, or refuse to participate in, any activity, policy, practice, assignment, or task (referred to in this subsection as a work assignment ) if— (A) the nurse reasonably believes such work assignment to be in violation of the minimum nurse staffing requirements of clause (ii) of subsection (b)(4)(C); or (B) the nurse reasonably believes that the nurse is not prepared by education, training, or experience to perform or comply with such work assignment without compromising the safety of a resident or jeopardizing the license of the nurse. (3) Retaliation for objection to or refusal of work assignment barred (A) No discharge, discrimination, or retaliation No nursing facility may discharge, retaliate, discriminate, or otherwise take adverse action in any manner with respect to any aspect of a nurse’s employment with the facility, including discharge, promotion, compensation, or terms, conditions, or privileges of employment, based on the nurse’s objection to, or refusal of, a work assignment under paragraph (2). (B) No filing of complaint No nursing facility may file a complaint or a report against a nurse with a State professional disciplinary agency because of the nurse’s objection to, or refusal of, a work assignment under paragraph (2). (4) Cause of action Any nurse (or a collective bargaining representative or legal representative of such nurse) against whom a nursing facility has taken an adverse action in violation of paragraph (3)(A), or against whom such facility has filed a complaint or report in violation of paragraph (3)(B), may (without regard to whether a complaint has been filed under paragraph (5) or (10)(B)) bring a cause of action in an appropriate district court of the United States. The legal burdens of proof specified in section 1221(e) of title 5, United States Code, shall be controlling for the purposes of any cause of action brought under this paragraph. A nurse who prevails on the cause of action may be entitled to one or more of the following: (A) Reinstatement. (B) Reimbursement of lost wages, compensation, and benefits. (C) Attorneys’ fees. (D) Court costs. (E) Other damages. (5) Complaint to Secretary Any individual may file a complaint with the Secretary against a nursing facility that violates a requirement described in paragraph (3). For any complaint filed, the Secretary shall— (A) receive and investigate the complaint; (B) determine whether a violation of such paragraph, as alleged in the complaint, has occurred; and (C) in the case that the Secretary determines that such a violation has occurred, issue an order that the complaining individual may not suffer any adverse action prohibited by paragraph (3) or (7). (6) Toll-Free telephone number (A) In general The Secretary shall provide for the establishment of a toll-free telephone hotline to provide information regarding the minimum nurse staffing requirements of clause (ii) of subsection (b)(4)(C) and to receive reports of violations of such requirements. (B) Notice to residents A nursing facility shall provide each resident admitted to the facility with the telephone number of the hotline described in subparagraph (A) and give notice to each such resident that such hotline may be used to report inadequate staffing or care. (7) Protection for reporting (A) Prohibition on retaliation or discrimination A nursing facility may not retaliate or discriminate in any manner against any resident, employee, or contract employee of the facility, or any other individual, on the basis that such resident, employee, contract employee, or individual (individually or in conjunction with another individual) has, in good faith— (i) presented a grievance or complaint; (ii) initiated or cooperated in any investigation or proceeding of any governmental entity, regulatory agency, or private accreditation body; (iii) made a civil claim or demand; or (iv) filed an action relating to the care, services, or conditions of the facility. (B) Good faith defined For purposes of this paragraph, an individual shall be deemed to be acting in good faith if the individual reasonably believes— (i) the information reported or disclosed is true; and (ii) a violation of the minimum nurse staffing requirements of clause (ii) of subsection (b)(4)(C) has occurred or may occur. (8) Prohibition on interference with rights (A) Exercise of rights A nursing facility may not— (i) interfere with, restrain, or deny the exercise, or attempt to exercise, by any individual of any right, procedure, or remedy provided or protected under this subsection; or (ii) coerce or intimidate any individual regarding the exercise, or attempt to exercise, such right. (B) Opposition to unlawful policies or practices A nursing facility may not retaliate or discriminate against any individual for opposing any policy, practice, or action of the facility which is alleged to violate, breach, or fail to comply with any provision of the minimum nurse staffing requirements of clause (ii) of subsection (b)(4)(C). (C) Prohibition on interference with protected communications A nursing facility may not make, adopt, or enforce any rule, regulation, policy, or practice which in any manner directly or indirectly prohibits, impedes, or discourages a nurse from, or intimidates, coerces, or induces a nurse regarding, engaging in free speech activities or disclosing information as provided under this subsection. (D) Prohibition on interference with collective action A nursing facility may not in any way interfere with the rights of nurses to organize, bargain collectively, and engage in concerted activity under section 7 of the National Labor Relations Act ( 29 U.S.C. 157 ). (9) Notice A nursing facility shall post in an appropriate location in each unit a conspicuous notice, in a form specified by the Secretary, that— (A) explains the rights of nurses, residents, and other individuals under this subsection; (B) includes a statement that a nurse, resident, or other individual may file a complaint with the Secretary against the facility for a violation of a requirement or a prohibition of this subsection; and (C) provides instructions on how to file such a complaint. (10) Enforcement (A) In general The Secretary shall enforce the requirements and prohibitions of this subsection in accordance with this paragraph. (B) Procedures for receiving and investigating complaints The Secretary shall establish procedures under which— (i) any individual may file a complaint alleging that a nursing facility has violated a requirement or a prohibition of this subsection; and (ii) any such complaint shall be investigated by the Secretary. (C) Remedies If the Secretary determines that a nursing facility has violated a requirement or prohibition of this subsection, the Secretary— (i) shall require the facility to establish a corrective action plan to prevent the recurrence of such violation; and (ii) may impose civil money penalties as described in subparagraph (D). (D) Civil penalties (i) In general In addition to any other penalties prescribed by law, the Secretary may impose civil penalties as follows: (I) Nursing facility liability The Secretary may impose on a nursing facility found to be in violation of this subsection a civil money penalty of— (aa) not more than $25,000 for the first knowing violation of this subsection by such facility; and (bb) not more than $50,000 for any subsequent knowing violation of this subsection by such facility. (II) Individual liability The Secretary may impose on an individual who— (aa) is employed by a nursing facility; and (bb) is found by the Secretary to have knowingly violated this subsection on behalf of the facility, a civil money penalty of not more than $20,000 for each such violation by the individual. (ii) Procedures The provisions of section 1128A of the Social Security Act (other than subsections (a) and (b)) shall apply with respect to a civil money penalty or proceeding under this subparagraph in the same manner as such provisions apply with respect to a civil money penalty or proceeding under such section 1128A. (E) Public notice of violations (i) Internet website The Secretary shall publish on the internet website of the Department of Health and Human Services the names of nursing facilities on which a civil money penalty has been imposed under this subsection, the violation for which such penalty was imposed, and such additional information as the Secretary determines appropriate. (ii) Change of ownership With respect to a nursing facility that had a change of ownership, as determined by the Secretary, penalties imposed on the facility while under previous ownership shall no longer be published by the Secretary pursuant to clause (i) after the 1-year period beginning on the date of such change of ownership. (F) Use of funds Funds collected by the Secretary pursuant to this subsection are authorized to be appropriated to implement the minimum nurse staffing requirements of clause (ii) of subsection (b)(4)(C). (11) Nurse defined In this subsection, the term nurse means a registered professional nurse, a licensed practical nurse, and a nurse aide. . (c) Effective date The amendments made by this section take effect on the date of enactment of this Act and shall apply with respect to objections to or refusals of work assignments, complaints, retaliations and other adverse actions, and interferences with rights that occur on or after the date that is one year after such date of enactment and with respect to notices provided on or after the date that is one year after such date of enactment. 7. Prohibiting pre-dispute arbitration agreements (a) Medicare Section 1819(c) of the Social Security Act ( 42 U.S.C. 1395i–3(c) ) is amended by adding at the end the following new paragraph: (7) Prohibition on use of pre-dispute arbitration agreements (A) In general A skilled nursing facility may not require, solicit, accept, or move to enforce a pre-dispute arbitration agreement from or on behalf of any resident, whether the agreement is made before, during, or after the resident’s admission to the facility, or from or on behalf of any employee, or contract employee of the facility, or any other individual if such individual is alleged to be engaged in conduct protected under subsection (k). (B) Application This paragraph shall apply to the skilled nursing facility and to any other business or person providing or responsible for providing skilled nursing services to the resident. (C) No validity or enforcement A pre-dispute arbitration agreement shall not be valid or specifically enforceable against a resident or former resident of a skilled nursing facility, without regard to whether the agreement was made prior to or after the effective date of this paragraph. (D) Definition of pre-dispute arbitration agreement In this paragraph, the term pre-dispute arbitration agreement means any agreement to arbitrate a dispute when the dispute has arisen after such agreement has been made. (E) Judicial review A determination as to whether and how this paragraph applies to an arbitration agreement shall be determined under Federal law by a court of competent jurisdiction, rather than an arbitrator, without regard to whether the party opposing arbitration challenges such agreement specifically or in conjunction with any other term of the contract containing such agreement. . (b) Medicaid (1) Home and community-based services and home health care services Section 1915 of the Social Security Act ( 42 U.S.C. 1396n ) is amended by adding at the end the following new subsection: (l) Prohibiting pre-Dispute arbitration agreements (1) In general For home and community-based services or home health care services provided under a waiver under this section, section 1902(a)(10)(D), or any other provision authorizing the provision of home and community-based services or home health care services under this title, the provider of such services (and any employee, agent, related entity, or affiliate of such provider) shall not require, solicit, or accept a pre-dispute arbitration agreement from or on behalf of any individual receiving such services, whether the agreement is made before, during, or after the first date on which services are received, or from or on behalf of any employee, or contract employee of the provider, or any other individual if such individual is alleged to be engaged in conduct protected under section 1919(k). A pre-dispute arbitration agreement between such a provider (or entity or person) and an individual receiving services (or who formerly received services) shall not be valid or enforceable, without regard to whether such agreement was made prior to the effective date of this subsection. (2) Definition of pre-dispute arbitration agreement The term pre-dispute arbitration agreement means any agreement to arbitrate a dispute when the dispute has arisen after such agreement has been made. (3) Judicial review A determination as to whether and how this subsection applies to an arbitration agreement shall be determined under Federal law by a court of competent jurisdiction, rather than an arbitrator, without regard to whether the party opposing arbitration challenges such agreement specifically or in conjunction with any other term of the contract containing such agreement. . (2) Nursing facilities Section 1919(c) of the Social Security Act ( 42 U.S.C. 1396r(c) ) is amended by adding at the end the following new paragraph: (9) Prohibition on use of pre-dispute arbitration agreements (A) In general A nursing facility may not require, solicit, accept, or move to enforce a pre-dispute arbitration agreement from or on behalf of any resident, whether the agreement is made before, during, or after the resident’s admission to the facility, or from or on behalf of any employee, or contract employee of the facility, or any other individual if such individual is alleged to be engaged in conduct protected under subsection (k). (B) Application This paragraph shall apply to the nursing facility and to any other business or person providing or responsible for providing nursing services to the resident. (C) No validity or enforcement A pre-dispute arbitration agreement shall not be valid or specifically enforceable against a resident or former resident of a nursing facility, without regard to whether the agreement was made prior to or after the effective date of this paragraph. (D) Definition of pre-dispute arbitration agreement In this paragraph, the term pre-dispute arbitration agreement means any agreement to arbitrate a dispute when the dispute has arisen after such agreement has been made. (E) Judicial review A determination as to whether and how this paragraph applies to an arbitration agreement shall be determined under Federal law by a court of competent jurisdiction, rather than an arbitrator, without regard to whether the party opposing arbitration challenges such agreement specifically or in conjunction with any other term of the contract containing such agreement. . 8. Standardized protocol for obtaining informed consent from residents prior to prescribing psychotropic drugs (a) Standardized protocol (1) Skilled nursing facilities Section 1819(b) of the Social Security Act ( 42 U.S.C. 1395i–3(b) ) is amended by adding at the end the following new paragraph: (9) Standardized protocol for obtaining informed consent from a resident prior to prescribing psychotropic drugs for a use not approved by the Food and Drug Administration (A) Protocol Not later than the date that is one year after the date of the enactment of this paragraph, the Secretary, taking into account the results of the study conducted by the Comptroller General of the United States under section 8(a)(3) of the Quality Care for Nursing Home Residents Act of 2019 and in consultation with stakeholder groups (including residents of skilled nursing facilities, family members of such residents, advocates for such residents, long-term care ombudsmen, and providers), shall develop a standardized protocol for skilled nursing facilities to obtain written informed consent, in accordance with this paragraph, from a resident (or, if applicable, the resident’s designated health care agent or other surrogate under State law or regulation) prior to prescribing a psychotropic drug to the resident for a use not approved by the Food and Drug Administration. (B) Requirements The standardized protocol developed under subparagraph (A) shall include the following: (i) A requirement, with respect to a resident, that— (I) the facility, with the involvement of the prescriber, inform the resident (or, if applicable, the resident’s designated health care agent or other surrogate under State law or regulation) of— (aa) possible side effects and risks associated with the psychotropic drug, including the mention of any black box warning ; (bb) treatment modalities that were attempted prior to the use of the psychotropic drug; and (cc) any other information the Secretary determines appropriate; (II) the resident (or, if applicable, the resident’s designated health care agent or other surrogate under State law or regulation) provide written informed consent to the administration of the psychotropic drug; and (III) the administration of the psychotropic drug is in accordance with any plan of care that the resident has in place, including non-pharmacological interventions as appropriate that can effectively address underlying medical and environmental causes of behavioral disorders. (ii) An alternative protocol for obtaining such written informed consent— (I) in the case of emergencies; and (II) in the absence of a clearly identified designated health care agent or other surrogate under State law or regulation. (iii) Other items determined appropriate by the Secretary. (C) Timing of informed consent Under the standardized protocol, a skilled nursing facility shall obtain the written informed consent described in subparagraph (A), with respect to a psychotropic drug and a resident of the facility— (i) prior to the initial prescribing of such psychotropic drug to such resident if such resident does not have a current prescription for such psychotropic drug at the time such resident is admitted to the facility; and (ii) at least once a month to the extent that the administration of such psychotropic drug to such resident is in accordance with the plan of care that the resident has in place. (D) Compliance Effective beginning on the date that is one year and 180 days after the date of the enactment of this paragraph, a skilled nursing facility shall comply with the standardized protocol developed under subparagraph (A). (E) No preemption Nothing in this paragraph shall preempt any provision of State or Federal law that provides broader rights with respect to written informed consent for residents of facilities. . (2) Nursing facilities Section 1919(b) of the Social Security Act ( 42 U.S.C. 1396r(b) ) is amended by adding at the end the following new paragraph: (9) Standardized protocol for obtaining informed consent from a resident prior to prescribing psychotropic drugs for a use not approved by the Food and Drug Administration (A) Protocol Not later than the date that is one year after the date of the enactment of this paragraph, the Secretary, taking into account the results of the study conducted by the Comptroller General of the United States under section 8(a)(3) of the Quality Care for Nursing Home Residents Act of 2019 and in consultation with stakeholder groups (including residents of skilled nursing facilities, family members of such residents, advocates for such residents, long-term care ombudsmen, and providers), shall develop a standardized protocol for nursing facilities to obtain written informed consent, in accordance with this paragraph, from a resident (or, if applicable, the resident’s designated health care agent or other surrogate under State law or regulation) prior to prescribing a psychotropic drug to the resident for a use not approved by the Food and Drug Administration. (B) Requirements The standardized protocol developed under subparagraph (A) shall include the following: (i) A requirement, with respect to a resident, that— (I) the facility, with the involvement of the prescriber, inform the resident (or, if applicable, the resident’s designated health care agent or other surrogate under State law or regulation) of— (aa) possible side effects and risks associated with the psychotropic drug, including the mention of any black box warning ; (bb) treatment modalities that were attempted prior to the use of the psychotropic drug; and (cc) any other information the Secretary determines appropriate; (II) the resident (or, if applicable, the resident’s designated health care agent or other surrogate under State law or regulation) provide written informed consent to the administration of the psychotropic drug; and (III) the administration of the psychotropic drug is in accordance with any plan of care that the resident has in place, including non-pharmacological interventions as appropriate that can effectively address underlying medical and environmental causes of behavioral disorders. (ii) An alternative protocol for obtaining such written informed consent— (I) in the case of emergencies; and (II) in the absence of a clearly identified designated health care agent or other surrogate under State law or regulation. (iii) Other items determined appropriate by the Secretary. (C) Timing of informed consent Under the standardized protocol, a nursing facility shall obtain the written informed consent described in subparagraph (A), with respect to a psychotropic drug and a resident of the facility— (i) prior to the initial prescribing of such psychotropic drug to such resident if such resident does not have a current prescription for such psychotropic drug at the time such resident is admitted to the facility; and (ii) at least once a month to the extent that the administration of such psychotropic drug to such resident is in accordance with the plan of care that the resident has in place. (D) Compliance Effective beginning on the date that is one year and 180 days after the date of the enactment of this paragraph, a nursing facility shall comply with the standardized protocol developed under subparagraph (A). (E) No preemption Nothing in this paragraph shall preempt any provision of State or Federal law that provides broader rights with respect to written informed consent for residents of facilities. . (3) GAO study and report on informed consent laws with respect to prescribing of psychotropic drugs (A) Study The Comptroller General of the United States (in this paragraph referred to as the Comptroller General ) shall conduct a study of State laws and regulations concerning informed consent with respect to the administration of a psychotropic drug with regard to the effectiveness of such laws and practices in changing the frequency of prescribing of psychotropic drugs to older adults. The study shall include an analysis as to whether in the case of States that have not enacted such informed consent laws, such States have developed other mechanisms to guide appropriate prescribing of psychotropic drugs in older adults with dementia. (B) Report Not later than 180 days after the date of enactment of this Act, the Comptroller General shall submit to the Secretary of Health and Human Services and to Congress a report containing the results of the study conducted under subparagraph (A), together with such recommendations as the Comptroller General determines appropriate. (b) Development of measure of utilization of psychotropic drugs for inclusion on Nursing Home Compare website (1) Medicare Section 1819(i) of the Social Security Act ( 42 U.S.C. 1395i–3(i) ) is amended— (A) by redesignating paragraph (3) as paragraph (4); and (B) by inserting after paragraph (2) the following new paragraph: (3) Development of measure of utilization of psychotropic drugs (A) In general Not later than the date that is one year after the date of the enactment of this paragraph, the Secretary shall include a measure of the utilization of psychotropic drugs for each skilled nursing facility for inclusion on such website (or a successor website) as part of the quality measures or health inspections measures, or both such measures, under the Five-Star Quality Rating System established by the Administrator of the Centers for Medicare & Medicaid Services. (B) Considerations In developing the measure under subparagraph (A), the Secretary shall take into account special patient populations, special care units, appropriate diagnoses, and other factors, as determined appropriate by the Secretary. . (2) Medicaid Section 1919(i) of the Social Security Act ( 42 U.S.C. 1396r(i) ) is amended— (A) by redesignating paragraph (3) as paragraph (4); and (B) by inserting after paragraph (2) the following new paragraph: (3) Development of measure of utilization of psychotropic drugs (A) In general Not later than the date that is one year after the date of the enactment of this paragraph, the Secretary shall include a measure of the utilization of psychotropic drugs for each nursing facility for inclusion on such website (or a successor website) as part of the quality measures or health inspections measures, or both such measures, under the Five-Star Quality Rating System established by the Administrator of the Centers for Medicare & Medicaid Services. (B) Considerations In developing the measure under subparagraph (A), the Secretary shall take into account special patient populations, special care units, appropriate diagnoses, and other factors, as determined appropriate by the Secretary. .