,i  #aafth ,,congress  #ast ,session    
,h4 ,r4 #ebaf  ,,in ,,the ,,house ,,of  
,,representatives  ,november #ba1 #bjai 
,ms4 ,schakowsky 7for herself1 ,mrs4    
,hayes1 ,mr4 ,garamendi1 ,mr4 ,ryan1    
,mr4 ,carson of ,indiana1 ,ms4 ,moore1  
,ms4 ,roybal-,allard1 ,mrs4 ,carolyn ,b4
 ,maloney of ,new ,york1 ,mrs4 ,dingell1
 ,ms4 ,de,lauro1 ,ms4 ,bass1 ,ms4       
,johnson of ,texas1 ,mr4 ,danny ,k4     
,davis of ,illinois1 ,mr4 ,hastings1    
,mr4 ,payne1 ,ms4 ,matsui1 ,ms4         
,underwood1 ,ms4 ,jayapal1 ,ms4         
,pressley1 ,ms4 ,judy ,chu of           
,california1 ,ms4 ,clarke of ,new ,york1
 ,mr4 ,khanna1 ,mr4 ,deutch1 ,mr4       
,de,saulnier1 ,ms4 ,lee of ,california1 
and ,mr4 ,tonko7 introduced the         
following bill2 which was referred to   
the ,committee on ,ways and ,means1 and 
in addition to the ,committee on ,energy
 and ,commerce1 for a period to be      
subsequently determined by the ,speaker1
 in each case for consideration of such 
provisions as fall within the           

jurisdiction of the committee concerned 
,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 program1 and for other        
purposes4  #a4 ,short title ,this ,act  
may be cited as the ,quality ,care for  
,nursing ,home ,residents ,act of #bjai4
  #b4 ,minimum nurse staffing           
requirements for skilled nursing        
facilities under ,medicare program and  
nursing facilities under ,medicaid      
program  7a7 ,medicare  7#a7 ,in general
 ,subparagraph 7,c7 of section          
#ahai7;b77#d7 of the ,social ,security  
,act 7#db ,u4,s4,c4 #acie;i-#c7;b77#d77 
is amended--  7,a7 in clause 7i7-- 7i7  
by amending the clause heading to read  
as follows3 ,general requirements before
 #bjbj2 and  7ii7 by striking ,except as
 provided in clause 7ii71 and inserting 
,except as provided in clause 7iii71    

with respect to skilled nursing facility
 services provided before ,january #a1  
#bjbj12  7,b7 by redesignating clause   
7ii7 as clause 7iii72 and  7,c7 by      
inserting after clause 7i7 the following
 new clause3  7ii7 ,general requirements
 after #bjai  7,i7 ,in general ,with    
respect to skilled nursing facility     
services provided on or after ,january  
#a1 #bjbj1 a skilled nursing facility   
must--  7aa7 provide nursing services   
that are sufficient to meet the nursing 
needs of its residents on a #bd-;hour   
basis1 to be divided into day shifts1   
evening shifts1 and night shifts2  7bb7 
provide for minimum nurse staffing      
levels with respect to each such shift1 
in accordance with this clause2 and     
7cc7 ensure that1 in carrying out items 
7aa7 and 7bb71 a total minimum of #d4a  
hours of care is provided per resident  
per day1 with #j4ge hours of care of    
such total minimum provided by a        
registered professional nurse1 #j4ed    
hours of care of such total minimum     

provided by a licensed practical nurse1 
and #b4ha hours of care of such total   
minimum provided by a nurse aide 7as    
defined in paragraph 7#e77;,f774  7,,ii7
 ,day shifts ,with respect to a day     
shift1 the skilled nursing facility must
 have-- 7aa7 at least #a registered     
professional nurse for every #bh        
residents1 with a minimum of #j4bi hours
 of care provided per resident during   
each such shift2  7bb7 at least #a      
licensed practical nurse for every #dj  
residents1 with a minimum of #j4bj hours
 of care provided per resident during   
each such shift2 and  7cc7 at least #a  
nurse aide 7as defined in paragraph     
7#e77;,f77 for every #g residents1 with 
a minimum of #a4ad hours of care        
provided per resident during each such  
shift4  7,,iii7 ,evening shifts ,with   
respect to an evening shift1 the skilled
 nursing facility must have-- 7aa7 at   
least #a registered professional nurse  
for every #cj residents1 with a minimum 
of #j4bf hours of care provided per     

resident during each such shift2  7bb7  
at least #a licensed practical nurse for
 every #dj residents1 with a minimum of 
#j4bj hours of care provided per        
resident during each such shift2 and    
7cc7 at least #a nurse aide 7as defined 
in paragraph 7#e77;,f77 for every #g    
residents1 with a minimum of #a4ad hours
 of care provided per resident during   
each such shift4  7,,iv7 ,night shifts  
,with respect to a night shift1 the     
skilled nursing facility must have--    
7aa7 at least #a registered professional
 nurse for every #dj residents1 with a  
minimum of #j4bj hours of care provided 
per resident during such shift2  7bb7 at
 least #a licensed practical nurse for  
every #ef residents1 with a minimum of  
#j4ad hours of care provided per        
resident during such shift2 and  7cc7 at
 least #a nurse aide 7as defined in     
paragraph 7#e77;,f77 for every #ae      
residents1 with a minimum of #j4ec hours
 of care provided per resident during   
such shift4  7,v7 ,secretarial authority

 to establish higher minimum nurse      
staffing levels ,the ,secretary may     
establish and require skilled nursing   
facilities 7or1 at the ,secretary's     
discretion1 only skilled nursing        
facilities that have a higher percentage
 of residents with extensive care needs1
 as determined by the ,secretary7 to    
provide for minimum nurse staffing      
levels that are higher than the levels  
required under this clause4  7,,vi7     
,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 clause4  7,,vii7    
,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 clause1

 a skilled nursing facility may not     
count any time spent by a registered    
professional nurse1 licensed practical  
nurse1 or nurse aide on administrative  
services towards compliance with such   
requirements4  7,,viii7 ,definitions ,in
 this clause3 7aa7 ,administrative      
services ,the term administrative       
services means food preparation1        
housekeeping1 laundry services1         
maintenance services1 and other         
noncaregiving-related services1 as      
determined by the ,secretary4  7bb7 ,day
 shift ,the term day shift means1 with  
respect to a day and a skilled nursing  
facility1 an assigned work shift that is
 a period of #h consecutive hours1      
beginning not sooner than #f a4m4 in the
 time zone in which such facility is    
located and not later than #h a4m4 in   
such time zone4  7cc7 ,evening shift    
,the term evening shift means1 with     
respect to a day and a skilled nursing  
facility1 an assigned work shift that is
 a period of #h consecutive hours1      

beginning not sooner than #b p4m4 in the
 time zone in which such facility is    
located and not later than #d p4m4 in   
such time zone4  7dd7 ,night shift ,the 
term night shift means1 with respect to 
a day and a skilled nursing facility1 an
 assigned work shift that is a period of
 #h consecutive hours1 beginning not    
sooner than #aj p4m4 in the time zone in
 which such facility is located and not 
later than midnight in such time zone4  
4  7#b7 ,enforcement ,section #ahai7;h7 
of the ,social ,security ,act 7#db      
,u4,s4,c4 #acie;i-#c7;h77 is amended--  
7,a7 in paragraph 7#a71 by striking ,if 
a ,state finds1 on the basis of a       
standard and inserting ,subject to      
paragraph 7#g71 if a ,state finds1 on   
the basis of a standard2  7,b7 in       
paragraph 7#b71 by striking ,with       
respect to and inserting ,subject to    
paragraph 7#g71 with respect to2 and    
7,c7 by adding at the end the following 
new paragraph3  7#g7 ,special           
enforcement process with respect to     

minimum nurse staffing requirements     
7,a7 ,in general ,if a ,state finds1 on 
the basis of a standard1 extended1 or   
partial extended survey under subsection
 7g77#b7 or otherwise1 that a skilled   
nursing facility does not meet the      
minimum staffing requirements of clause 
7ii7 of subsection 7b77#d77;,c7 with    
respect to skilled nursing facility     
services provided on or after ,january  
#a1 #bjbj1 the ,state shall recommend to
 the ,secretary that the ,secretary take
 such actions as described in subclauses
 7,i7 and 7,,ii7 of subparagraph        
7,b77i74  7,b7 ,secretarial authority   
7i7 ,in general ,with respect to any    
skilled nursing facility in a ,state1 if
 the ,secretary finds1 or pursuant to a 
recommendation of the ,state under      
subparagraph 7,a7 finds1 that a skilled 
nursing facility does not meet the      
minimum staffing requirements of clause 
7ii7 of subsection 7b77#d77;,c7 with    
respect to skilled nursing facility     
services provided on or after ,january  

#a1 #bjbj1 the ,secretary shall--  7,i7 
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 finding2 and  
7,,ii7 impose a civil money penalty in  
an amount not to exceed #aj1jjj for each
 day of noncompliance4 ,the provisions  
of section #aabh;,a 7other than         
subsections 7a7 and 7b77 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 #aabh;,a7a74   
7ii7 ,reduction of civil money penalties
 in certain circumstances ,subject to   
clause 7iii71 in the case where a       
skilled nursing facility self-reports   
and promptly corrects a deficiency for  
which a penalty was imposed under clause
 7i77,,ii7 not later than #aj calendar  
days after the date of such imposition1 
the ,secretary may reduce the amount of 
the penalty imposed by--  7,i7 not more 

than #ej percent2 or  7,,ii7 in the case
 that the facility was penalized under  
this subsection within the three-year   
period preceding the date of such       
imposition1 not more than #be percent4  
7iii7 ,prohibitions on reduction for    
certain deficiencies  7,i7 ,repeat      
deficiencies ,the ,secretary may not    
reduce the amount of a penalty under    
clause 7ii7 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 deficiency4  7,,ii7 ,certain     
other deficiencies ,the ,secretary may  
not reduce the amount of a penalty under
 clause 7ii7 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 harm1     
immediately jeopardizes the health or   
safety of a resident or residents of the
 facility1 or results in the death of a 
resident of the facility4  7iv7         
,repeated noncompliance ,in the case of 

a skilled nursing facility which1 on    
three consecutive standard surveys      
conducted under subsection 7g77#b71 has 
been found as not meeting the minimum   
staffing requirements of clause 7ii7 of 
subsection 7b77#d77;,c7 with respect to 
skilled nursing facility services       
provided on or after ,january #a1 #bjbj1
 the ,secretary may 7regardless of the  
remedies provided for under clause      
7i77--  7,i7 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 7iii7 of      
paragraph 7#b77;,b71 except that the    
minimum staffing requirements of clause 
7ii7 of subsection 7b77#d77;,c7 shall be
 substituted for all the requirements of
 subsections 7b71 7c71 and 7d7 under    
such clause2  7,,ii7 monitor the        
facility under subsection 7g77#d77;,b7  
with respect to such minimum staffing   
requirements until the facility has     
demonstrated to the satisfaction of the 

,secretary that the facility is in      
compliance1 and will remain in          
compliance1 with such minimum staffing  
requirements2 or  7,,iii7 subject to    
section #aabh;,i7h71 terminate the      
facility's participation under this     
title4  ,if the facility's participation
 under this title is terminated under   
this clause1 the ,state shall provide   
for the safe and orderly transfer of the
 residents eligible under this title1   
consistent with the requirements of     
subsection 7c77#b7 and section          
#aabh;,i7h74  7v7 ,public notice of     
violations  7,i7 ,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 7ii7 of          
subsection 7b77#d77;,c7 with respect to 
skilled nursing facility services       
provided on or after ,january #a1 #bjbj4
  7,,ii7 ,change of ownership ,with     

respect to a skilled nursing facility   
whose name is published under subclause 
7,i7 and has a change of ownership1 as  
determined by the ,secretary1 after the 
date of such publication1 the ,secretary
 shall remove the name of such facility 
from the website described under such   
subclause after the #a-year period      
beginning on the date of such change of 
ownership4  4  7#c7 ,conforming         
amendment ,item 7a7 of section          
#ahai7;f77#b77;,b77iii77,i7 of the      
,social ,security ,act 7#db ,u4,s4,c4   
#acie;i-#c7;f77#b77;,b77iii77,i77 is    
amended by striking subsection          
7b77#d77;,c77ii77,,ii7 and inserting    
subsection 7b77#d77;,c77iii77,,ii74  7b7
 ,medicaid  7#a7 ,in general            
,subparagraph 7,c7 of section           
#aiai7;b77#d7 of the ,social ,security  
,act 7#db ,u4,s4,c4 #acifr7b77#d77 is   
amended--  7,a7 in clause 7i7-- 7i7 in  
the clause heading1 by inserting after  
,general requirements the following     
before #bjbj2  7ii7 in the matter       

preceding subclause 7,i71 by inserting  
after ,october #a1 #aiij1 the following3
 and before ,january #a1 #bjbj12  7iii7 
in subclause 7,i71 by striking clause   
7ii7 and inserting clause 7iii72 and    
7iv7 in subclause 7,,ii71 by striking   
clause 7ii7 and inserting clause 7iii72 
7,b7 by redesignating clauses 7ii7 and  
7iii7 as clauses 7iii7 and 7iv71        
respectively2 and  7,c7 by inserting    
after clause 7i7 the following new      
clause3  7ii7 ,general requirements     
after #bjai  7,i7 ,in general ,with     
respect to nursing facility services    
provided on or after ,january #a1 #bjbj1
 a nursing facility must--  7aa7 provide
 nursing services that are sufficient to
 meet the nursing needs of its residents
 on a #bd-;hour basis1 to be divided    
into day shifts1 evening shifts1 and    
night shifts2  7bb7 provide for minimum 
nurse staffing levels with respect to   
each such shift1 in accordance with this
 clause2 and  7cc7 ensure that1 in      
carrying out items 7aa7 and 7bb71 a     

total minimum of #d4a hours of care is  
provided per resident per day1 with     
#j4ge hours of care of such total       
minimum provided by a registered        
professional nurse1 #j4ed hours of care 
of such total minimum provided by a     
licensed practical nurse1 and #b4ha     
hours of care of such total minimum     
provided by a nurse aide 7as defined in 
paragraph 7#e77;,f774  7,,ii7 ,day      
shifts ,with respect to a day shift1 the
 nursing facility must have-- 7aa7 at   
least #a registered professional nurse  
for every #bh residents1 with a minimum 
of #j4bi hours of care provided per     
resident during each such shift2  7bb7  
at least #a licensed practical nurse for
 every #dj residents1 with a minimum of 
#j4bj hours of care provided per        
resident during each such shift2 and    
7cc7 at least #a nurse aide 7as defined 
in paragraph 7#e77;,f77 for every #g    
residents1 with a minimum of #a4ad hours
 of care provided per resident during   
each such shift4  7,,iii7 ,evening      

shifts ,with respect to an evening      
shift1 the nursing facility must have-- 
7aa7 at least #a registered professional
 nurse for every #cj residents1 with a  
minimum of #j4bf hours of care provided 
per resident during each such shift2    
7bb7 at least #a licensed practical     
nurse for every #dj residents1 with a   
minimum of #j4bj hours of care provided 
per resident during each such shift2 and
  7cc7 at least #a nurse aide 7as       
defined in paragraph 7#e77;,f77 for     
every #g residents1 with a minimum of   
#a4ad hours of care provided per        
resident during each such shift4  7,,iv7
 ,night shifts ,with respect to a night 
shift1 the nursing facility must have-- 
7aa7 at least #a registered professional
 nurse for every #dj residents1 with a  
minimum of #j4bj hours of care provided 
per resident during such shift2  7bb7 at
 least #a licensed practical nurse for  
every #ef residents1 with a minimum of  
#j4ad hours of care provided per        
resident during such shift2 and  7cc7 at

 least #a nurse aide 7as defined in     
paragraph 7#e77;,f77 for every #ae      
residents1 with a minimum of #j4ec hours
 of care provided per resident during   
such shift4  7,v7 ,secretarial authority
 to establish higher minimum nurse      
staffing levels ,the ,secretary may     
establish and require nursing facilities
 7or1 at the ,secretary's discretion1   
only nursing facilities that have a     
higher percentage of residents with     
extensive care needs1 as determined by  
the ,secretary7 to provide for minimum  
nurse staffing levels that are higher   
than the levels required under this     
clause4  7,,vi7 ,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 clause4  7,,vii7 ,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 clause1 a nursing facility   
may not count any time spent by a       
registered professional nurse1 licensed 
practical nurse1 or nurse aide on       
administrative services towards         
compliance with such requirements4      
7,,viii7 ,definitions ,in this clause3  
7aa7 ,administrative services ,the term 
administrative services means food      
preparation1 housekeeping1 laundry      
services1 maintenance services1 and     
other noncaregiving-related services1 as
 determined by the ,secretary4  7bb7    
,day shift ,the term day shift means1   
with respect to a day and a nursing     
facility1 an assigned work shift that is
 a period of #h consecutive hours1      
beginning not sooner than #f a4m4 in the
 time zone in which such facility is    
located and not later than #h a4m4 in   
such time zone4  7cc7 ,evening shift    

,the term evening shift means1 with     
respect to a day and a nursing facility1
 an assigned work shift that is a period
 of #h consecutive hours1 beginning not 
sooner than #b p4m4 in the time zone in 
which such facility is located and not  
later than #d p4m4 in such time zone4   
7dd7 ,night shift ,the term night shift 
means1 with respect to a day and a      
nursing facility1 an assigned work shift
 that is a period of #h consecutive     
hours1 beginning not sooner than #aj    
p4m4 in the time zone in which such     
facility is located and not later than  
midnight in such time zone4  4  7#b7    
,enforcement ,section #aiai7;h7 of the  
,social ,security ,act 7#db ,u4,s4,c4   
#acifr7h77 is amended-- 7,a7 in         
paragraph 7#a71 by striking ,if a ,state
 finds1 on the basis of a standard and  
inserting ,subject to paragraph 7#aj71  
if a ,state finds1 on the basis of a    
standard2  7,b7 in paragraph 7#b7-- 7i7 
in subparagraph 7,c71 by striking ,if a 
nursing facility and inserting ,subject 

to paragraph 7#aj71 if a nursing        
facility2 and  7ii7 in subparagraph     
7,d71 by striking ,in the case of and   
inserting ,subject to paragraph 7#aj71  
in the case of2  7,c7 in paragraph      
7#c7--  7i7 in subparagraph 7,a71 by    
inserting before the period the         
following3 and the remedies described in
 paragraph 7#aj77;,b72 and  7ii7 in     
subparagraph 7,b71 by striking ,with    
respect to and inserting ,subject to    
paragraph 7#aj71 with respect to2 and   
7,d7 by adding at the end the following 
new paragraph3  7#aj7 ,special          
enforcement process with respect to     
minimum nurse staffing requirements     
7,a7 ,in general ,if a ,state finds1 on 
the basis of a standard1 extended1 or   
partial extended survey under subsection
 7g77#b7 or otherwise1 that a nursing   
facility does not meet the minimum      
staffing requirements of clause 7ii7 of 
subsection 7b77#d77;,c7 with respect to 
nursing facility services provided on or
 after ,january #a1 #bjbj1 the ,state   

shall--  7i7 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 finding2 and  
7ii7 recommend to the ,secretary that   
the ,secretary impose the civil money   
penalty described in subparagraph 7,b74 
7,b7 ,secretarial authority  7i7 ,in    
general ,with respect to any nursing    
facility in a ,state other than a ,state
 nursing facility1 if the ,secretary    
finds that such a nursing facility does 
not meet the minimum staffing           
requirements of clause 7ii7 of          
subsection 7b77#d77;,c7 with respect to 
nursing facility services provided on or
 after ,january #a1 #bjbj1 the          
,secretary shall--  7,i7 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 finding2 and  7,,ii7 impose a   

civil money penalty in an amount not to 
exceed #aj1jjj for each day of          
noncompliance4 ,the provisions of       
section #aabh;,a 7other than subsections
 7a7 and 7b77 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 #aabh;,a7a74   
7ii7 ,reduction of civil money penalties
 in certain circumstances ,subject to   
clause 7iii71 in the case where a       
nursing facility self-reports and       
promptly corrects a deficiency for which
 a penalty was imposed under clause     
7i77,,ii7 not later than #aj calendar   
days after the date of such imposition1 
the ,secretary may reduce the amount of 
the penalty imposed by--  7,i7 not more 
than #ej percent2 or  7,,ii7 in the case
 that the facility was penalized under  
this subsection within the three-year   
period preceding the date of such       
imposition1 not more than #be percent4  
7iii7 ,prohibitions on reduction for    

certain deficiencies  7,i7 ,repeat      
deficiencies ,the ,secretary may not    
reduce the amount of a penalty under    
clause 7ii7 if the ,secretary had       
reduced a penalty imposed on the nursing
 facility in the preceding year under   
such clause with respect to a repeat    
deficiency4  7,,ii7 ,certain other      
deficiencies ,the ,secretary may not    
reduce the amount of a penalty under    
clause 7ii7 if the penalty is imposed on
 the nursing facility for a deficiency  
that is found to result in a pattern of 
harm or widespread harm1 immediately    
jeopardizes the health or safety of a   
resident or residents of the facility1  
or results in the death of a resident of
 the facility4  7iv7 ,repeated          
noncompliance ,in the case of a nursing 
facility which1 on three consecutive    
standard surveys conducted under        
subsection 7g77#b71 has been found as   
not meeting the minimum staffing        
requirements of clause 7ii7 of          
subsection 7b77#d77;,c7 with respect to 

nursing facility services provided on or
 after ,january #a1 #bjbj1 the          
,secretary may 7regardless of the       
remedies provided for under clause      
7i77--  7,i7 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 7iii7 of      
paragraph 7#c77;,c71 except that the    
minimum staffing requirements of clause 
7ii7 of subsection 7b77#d77;,c7 shall be
 substituted for all the requirements of
 subsections 7b71 7c71 and 7d7 under    
such clause2  7,,ii7 monitor the        
facility under subsection 7g77#d77;,b7  
with respect to such minimum staffing   
requirements until the facility has     
demonstrated to the satisfaction of the 
,secretary that the facility is in      
compliance1 and will remain in          
compliance1 with such minimum staffing  
requirements2 or  7,,iii7 subject to    
section #aabh;,i7h71 terminate the      
facility's participation under this     

title4  ,if the facility's participation
 under this title is terminated under   
this clause1 the ,state shall provide   
for the safe and orderly transfer of the
 residents eligible under this title1   
consistent with the requirements of     
subsection 7c77#b7 and section          
#aabh;,i7h74  7v7 ,public notice of     
violations  7,i7 ,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 7ii7 of subsection 7b77#d77;,c7  
with respect to skilled nursing facility
 services provided on or after ,january 
#a1 #bjbj4  7,,ii7 ,change of ownership 
,with respect to a nursing facility     
whose name is published under subclause 
7,i7 and has a change of ownership1 as  
determined by the ,secretary1 after the 
date of such publication1 the ,secretary
 shall remove the name of such facility 
from the website described under such   

subclause after the #a-year period      
beginning on the date of such change of 
ownership4  4  7#c7 ,conforming         
amendments  7,a7 ,clause 7iii7 of       
section #aiai7;b77#d77;,c7 of the       
,social ,security ,act 7#db ,u4,s4,c4   
#acifr7b77#d77;,c771 as redesignated by 
paragraph 7#a77;,b71 is amended by      
striking subject to clause 7iii7 and    
inserting subject to clause 7iv74  7,b7 
,item 7a7 of section                    
#aiai7;f77#b77;,b77iii77,i7 of the      
,social ,security ,act 7#db ,u4,s4,c4   
#acifr7f77#b77;,b77iii77,i77 is amended 
by striking subsection 7b77#d77;,c77ii7 
and inserting subsection                
7b77#d77;,c77iii74  7,c7 ,paragraph 7#i7
 of section #aiai7;f7 of the ,social    
,security ,act 7#db ,u4,s4,c4 #acifr7f77
 is amended by striking subsection      
7b77#d77;,c77ii7 and inserting          
subsection 7b77#d77;,c77iii74  7c7      
,studies and reports regarding impact of
 minimum nurse staffing requirements    
7#a7 ,initial study and report  7,a7 ,in

 general ,not later than ,june #a1      
#bjba1 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--  7i7 on the impact of
 the minimum nurse staffing requirements
 added by subsection 7a7 on the         
reimbursement levels of skilled nursing 
facilities under the ,medicare program  
under title ,,xviii of the ,social      
,security ,act 7#db ,u4,s4,c4 #acie et  
seq47 and the adequacy of personnel     
numbers in such skilled nursing         
facilities to meet such minimum nurse   
staffing requirements2  7ii7 on the     
impact of the minimum nurse staffing    
requirements added by subsection 7b7 on 
the reimbursement levels of nursing     
facilities under the ,medicaid program  
under title ,,xix of the ,social        
,security ,act 7#db ,u4,s4,c4 #acif et  

seq47 and the adequacy of personnel     
numbers in such nursing facilities to   
meet such minimum nurse staffing        
requirements2 and  7iii7 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 7a7 and 7b7 for such skilled
 nursing facilities and nursing         
facilities1 respectively1 including     
methods for attracting and retaining    
such personnel4  7,b7 ,considerations   
,in conducting the study required under 
subparagraph 7,a71 the ,secretary of    
,health and ,human ,services shall take 
into consideration--  7i7 the benefits  
of any increase in nurse staffing       
levels1 including with respect to       
workforce training and retention2  7ii7 
any decrease in the rate of workplace   
injuries2  7iii7 any changes in medical 

care costs for residents of skilled     
nursing facilities and nursing          
facilities2  7iv7 any decrease in       
hospitalization rates for such          
residents2  7v7 any changes in personnel
 and administrative costs for skilled   
nursing facilities and nursing          
facilities2 and  7vi7 any changes in    
recruiting and training costs4  7#b7    
,subsequent study and report ,not later 
than ,january #a1 #bjbc1 the ,secretary 
of ,health and ,human ,services shall   
conduct a follow-up study to the study  
conducted under paragraph 7#a77;,a7 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      
study4  #c4 ,disclosure of nurse        
staffing levels at skilled nursing      
facilities under ,medicare program and  
nursing facilities under ,medicaid      
program  7a7 ,medicare ,paragraph 7#h7  

of section #ahai7;b7 of the ,social     
,security ,act 7#db ,u4,s4,c4           
#acie;i-#c7;b77 is amended to read as   
follows3  7#h7 ,information on nurse    
staffing  7,a7 ,in general ,each day1 a 
skilled nursing facility shall post for 
each shift notices with-- 7i7 a         
description of the nurse staffing       
requirements applicable with respect to 
the facility and day under paragraph    
7#d77;,c72  7ii7 information on the     
number of registered professional       
nurses1 licensed practical nurses1 and  
nurse aides 7as defined in paragraph    
7#e77;,f77 assigned to provide direct   
care services to residents in the       
facility during the shift1 disaggregated
 by units in the facility2 and  7iii7 a 
statement that the facility is required1
 upon request1 to provide any nurse     
staffing information 7as described in   
this subparagraph7 of the facility from 
the preceding #ab-month period4  ,the   
information in such notices shall be    
written in a uniform manner1 printed in 

an easily readable #ad-point type font1 
and made available in appropriate       
languages1 as determined by the         
,secretary4 ,the skilled nursing        
facility shall make such notices        
available at each nurses' station in the
 facility and other areas in each unit  
of the facility1 as determined          
appropriate by the facility1 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 
facility4  7,b7 ,public availability of 
information ,a skilled nursing facility 
shall1 upon request1 make available to  
the public any nurse staffing           
information 7as described in            
subparagraph 7,a77 of the facility from 
the preceding #ab-month period4 ,in the 
case that the facility makes such       
information available as a paper copy1  
such facility may not charge for such   
copy an amount greater than the cost of 
making such copy4  4  7b7 ,medicaid     
,paragraph 7#h7 of section #aiai7;b7 of 

the ,social ,security ,act 7#db         
,u4,s4,c4 #acifr7b77 is amended to read 
as follows3  7#h7 ,information on nurse 
staffing  7,a7 ,in general ,each day1 a 
skilled nursing facility shall post for 
each shift notices with-- 7i7 a         
description of the nurse staffing       
requirements applicable with respect to 
the facility and day under paragraph    
7#d77;,c72  7ii7 information on the     
number of registered professional       
nurses1 licensed practical nurses1 and  
nurse aides 7as defined in paragraph    
7#e77;,f77 assigned to provide direct   
care services to residents in the       
facility during the shift1 disaggregated
 by units in the facility2 and  7iii7 a 
statement that the facility is required1
 upon request1 to provide any nurse     
staffing information 7as described in   
this subparagraph7 of the facility from 
the preceding #ab-month period4  ,the   
information in such notices shall be    
written in a uniform manner1 printed in 
an easily readable #ad-point type font1 

and made available in appropriate       
languages1 as determined by the         
,secretary4 ,the skilled nursing        
facility shall make such notices        
available at each nurses' station in the
 facility and other areas in each unit  
of the facility1 as determined          
appropriate by the facility1 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 
facility4  7,b7 ,public availability of 
information ,a skilled nursing facility 
shall1 upon request1 make available to  
the public any nurse staffing           
information 7as described in            
subparagraph 7,a77 of the facility from 
the preceding #ab-month period4  4  7c7 
,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    
enactment4  #d4 ,administrative staffing

 requirements for skilled nursing       
facilities under ,medicare program and  
nursing facilities under ,medicaid      
program  7a7 ,medicare ,paragraph 7#a7  
of section #ahai7;d7 of the ,social     
,security ,act 7#db ,u4,s4,c4           
#acie;i-#c7;d77 is amended-- 7#a7 by    
redesignating the second subparagraph   
7,c7 as subparagraph 7,e72 and  7#b7 by 
inserting after the first subparagraph  
7,c7 the following new subparagraph3    
7,d7 ,nursing management personnel  7i7 
,in general ,a skilled nursing facility 
must employ nursing management personnel
 in accordance with this subparagraph4  
7ii7 ,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 facility4 ,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 7as       

required under subsection 7b77#d77;,c774
  7iii7 ,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 facility1 except that in the case
 of a skilled nursing facility that has 
fewer than #ajj beds1 such facility may 
employ a registered professional nurse  
to serve part-time as the assistant     
director of nursing services of the     
facility4 ,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 facility4  7iv7   
,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 facility1 except that  
in the case of a skilled nursing        
facility that has fewer than #ajj beds1 

such facility may employ a registered   
professional nurse to serve part-time as
 the director of in-service education of
 the facility4 ,in carrying out the     
previous sentence1 a skilled nursing    
facility must1 to the extent practicable
 and appropriate1 employ a registered   
professional nurse who has received     
training in adult education and         
gerontology4  4  7b7 ,medicaid  7#a7 ,in
 general ,paragraph 7#a7 of section     
#aiai7;d7 of the ,social ,security ,act 
7#db ,u4,s4,c4 #acifr7d77 is amended by 
inserting after subparagraph 7,c7 the   
following new subparagraph3  7,d7       
,nursing management personnel  7i7 ,in  
general ,a nursing facility must employ 
nursing management personnel in         
accordance with this subparagraph4  7ii7
 ,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 facility4 ,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 7as       
required under subsection 7b77#d77;,c774
  7iii7 ,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     
facility1 except that in the case of a  
nursing facility that has fewer than    
#ajj beds1 such facility may employ a   
registered professional nurse to serve  
part-time as the assistant director of  
nursing services of the facility4 ,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 facility4
  7iv7 ,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 facility1   
except that in the case of a nursing    
facility that has fewer than #ajj beds1 
such facility may employ a registered   
professional nurse to serve part-time as
 the director of in-service education of
 the facility4 ,in carrying out the     
previous sentence1 a nursing facility   
must1 to the extent practicable and     
appropriate1 employ a registered        
professional nurse who has received     
training in adult education and         
gerontology4  4  7#b7 ,technical        
amendment ,paragraph 7#a7 of section    
#aiai7;d7 of the ,social ,security ,act 
7#db ,u4,s4,c4 #acifr7d77 is amended by 
redesignating subparagraph 7,v7 as      
subparagraph 7,e74  7c7 ,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 enactment4  #e4 ,nurse     

training requirements with respect to   
skilled nursing facilities under        
,medicare program and nursing facilities
 under ,medicaid program  7a7 ,medicare 
7#a7 ,orientation for registered        
professional nurses1 licensed practical 
nurses1 and nurse aides ,section        
#ahai7;d7 of the ,social ,security ,act 
7#db ,u4,s4,c4 #acie;i-#c7;d77 is       
amended by adding at the end the        
following new paragraph3  7#e7          
,orientations ,a skilled nursing        
facility must provide to registered     
professional nurses1 licensed practical 
nurses1 and nurse aides1 before such    
registered professional nurses1 licensed
 practical nurses1 and nurse aides are  
assigned to provide direct care services
 to residents in the facility1          
orientations providing education on the 
policies and emergency procedures of the
 facility and on residents' rights under
 this section4  4  7#b7 ,requirements   
for nurse aide training and competency  
evaluation programs and for nurse aide  

competency evaluation programs          
,subparagraph 7,a7 of section           
#ahai7;f77#b7 of the ,social ,security  
,act 7#db ,u4,s4,c4 #acie;i-#c7;f77#b77 
is amended--  7,a7 in the matter        
preceding clause 7i71 by inserting after
 #aihh the following3 1 and update1 as  
determined necessary by the ,secretary2 
7,b7 in clause 7i7--  7i7 by inserting  
after care of cognitively impaired      
residents1 the following3 care of older 
adults12  7ii7 by striking patient abuse
 prevention training1 and inserting     
patient abuse prevention training712 and
  7iii7 by striking #ge hours and       
inserting #abj hours2 and  7,c7 in      
clause 7ii7--  7i7 by striking          
requirement relating to and inserting   
requirements relating to 7,i72  7ii7 by 
inserting after care of cognitively     
impaired residents1 the following3 care 
of older adults12 and  7iii7 by striking
 and procedures and inserting 7,,ii7    
minimum hours of initial and ongoing    
training and retraining 7including not  

less than #abj hours in the case of     
initial training71 and 7,,iii7          
procedures4  7b7 ,medicaid  7#a7        
,orientation for registered professional
 nurses1 licensed practical nurses1 and 
nurse aides ,section #aiai7;d7 of the   
,social ,security ,act 7#db ,u4,s4,c4   
#acifr7d77 is amended by adding at the  
end the following new paragraph3  7#e7  
,orientations ,a nursing facility must  
provide to registered professional      
nurses1 licensed practical nurses1 and  
nurse aides1 before such registered     
professional nurses1 licensed practical 
nurses1 and nurse aides are assigned to 
provide direct care services to         
residents in the facility1 orientations 
providing education on the policies and 
emergency procedures of the facility and
 on residents' rights under this        
section4  4  7#b7 ,requirements for     
nurse aide training and competency      
evaluation programs and for nurse aide  
competency evaluation programs          
,subparagraph 7,a7 of section           

#aiai7;f77#b7 of the ,social ,security  
,act 7#db ,u4,s4,c4 #acifr7f77#b77 is   
amended--  7,a7 in the matter preceding 
clause 7i71 by inserting after #aihh the
 following3 1 and update1 as determined 
necessary by the ,secretary2  7,b7 in   
clause 7i7--  7i7 by inserting after    
care of cognitively impaired residents1 
the following3 care of older adults12   
7ii7 by striking patient abuse          
prevention training1 and inserting      
patient abuse prevention training712 and
  7iii7 by striking #ge hours and       
inserting #abj hours2 and  7,c7 in      
clause 7ii7--  7i7 by striking          
requirement relating to and inserting   
requirements relating to 7,i72  7ii7 by 
inserting after care of cognitively     
impaired residents1 the following3 care 
of older adults12 and  7iii7 by striking
 and procedures and inserting 7,,ii7    
minimum hours of initial and ongoing    
training and retraining 7including not  
less than #abj hours in the case of     
initial training71 and 7,,iii7          

procedures4  7c7 ,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 programs1 nurse aide         
competency evaluation programs1 and     
nurse orientations conducted on or after
 the date that is one year after such   
date of enactment4  #f4 ,whistleblower  
and resident protections  7a7 ,medicare 
,section #ahai of the ,social ,security 
,act 7#db ,u4,s4,c4 #acie;i-#c7 is      
amended by adding at the end the        
following new subsection3  7k7          
,whistleblower and resident protections 
7#a7 ,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 located1 to provide nursing 
care in the exclusive interests of the  

residents of the facility1 and to act as
 the residents' advocate4  7#b7         
,objection to or refusal of work        
assignment ,a nurse may object to1 or   
refuse to participate in1 any activity1 
policy1 practice1 assignment1 or task   
7referred to in this subsection as a    
work assignment7 if--  7,a7 the nurse   
reasonably believes such work assignment
 to be in violation of the minimum nurse
 staffing requirements of clause 7ii7 of
 subsection 7b77#d77;,c72 or  7,b7 the  
nurse reasonably believes that the nurse
 is not prepared by education1 training1
 or experience to perform or comply with
 such work assignment without           
compromising the safety of a resident or
 jeopardizing the license of the nurse4 
7#c7 ,retaliation for objection to or   
refusal of work assignment barred  7,a7 
,no discharge1 discrimination1 or       
retaliation ,no skilled nursing facility
 may discharge1 retaliate1 discriminate1
 or otherwise take adverse action in any
 manner with respect to any aspect of a 

nurse's employment with the facility1   
including discharge1 promotion1         
compensation1 or terms1 conditions1 or  
privileges of employment1 based on the  
nurse's objection to1 or refusal of1 a  
work assignment under paragraph 7#b74   
7,b7 ,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 to1 or 
refusal of1 a work assignment under     
paragraph 7#b74  7#d7 ,cause of action  
,any nurse 7or a collective bargaining  
representative or legal representative  
of such nurse7 against whom a skilled   
nursing facility has taken an adverse   
action in violation of paragraph        
7#c77;,a71 or against whom such facility
 has filed a complaint or report in     
violation of paragraph 7#c77;,b71 may   
7without regard to whether a complaint  
has been filed under paragraph 7#e7 or  
7#aj77;,b77 bring a cause of action in  
an appropriate district court of the    

,united ,states4 ,the legal burdens of  
proof specified in section #abba7;e7 of 
title #e1 ,united ,states ,code1 shall  
be controlling for the purposes of any  
cause of action brought under this      
paragraph4 ,a nurse who prevails on the 
cause of action may be entitled to one  
or more of the following3  7,a7         
,reinstatement4  7,b7 ,reimbursement of 
lost wages1 compensation1 and benefits4 
7,c7 ,attorneys' fees4  7,d7 ,court     
costs4  7,e7 ,other damages4  7#e7      
,complaint to ,secretary ,any individual
 may file a complaint with the          
,secretary against a skilled nursing    
facility that violates a requirement    
described in paragraph 7#c74 ,for any   
complaint filed1 the ,secretary shall-- 
7,a7 receive and investigate the        
complaint2  7,b7 determine whether a    
violation of such paragraph1 as alleged 
in the complaint1 has occurred2 and     
7,c7 in the case that the ,secretary    
determines that such a violation has    
occurred1 issue an order that the       

complaining individual may not suffer   
any adverse action prohibited by        
paragraph 7#c7 or 7#g74  7#f7           
,toll-,free telephone number  7,a7 ,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 7ii7 of          
subsection 7b77#d77;,c7 and to receive  
reports of violations of such           
requirements4  7,b7 ,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   
7,a7 and give notice to each such       
resident that such hotline may be used  
to report inadequate staffing4  7#g7    
,protection for reporting  7,a7         
,prohibition on retaliation or          
discrimination ,a skilled nursing       
facility may not retaliate or           
discriminate in any manner against any  
resident1 employee1 or contract employee

 of the facility1 or any other          
individual1 on the basis that such      
resident1 employee1 contract employee1  
or individual 7individually or in       
conjunction with another individual7    
has1 in good faith--  7i7 presented a   
grievance or complaint2  7ii7 initiated 
or cooperated in any investigation or   
proceeding of any governmental entity1  
regulatory agency1 or private           
accreditation body2  7iii7 made a civil 
claim or demand2 or  7iv7 filed an      
action relating to the care1 services1  
or conditions of the facility4  7,b7    
,good faith defined ,for purposes of    
this paragraph1 an individual shall be  
deemed to be acting in good faith if the
 individual reasonably believes--  7i7  
the information reported or disclosed is
 true2 and  7ii7 a violation of the     
minimum nurse staffing requirements of  
clause 7ii7 of subsection 7b77#d77;,c7  
has occurred or may occur4  7#h7        
,prohibition on interference with rights
  7,a7 ,exercise of rights ,a skilled   

nursing facility may not-- 7i7 interfere
 with1 restrain1 or deny the exercise1  
or attempt to exercise1 by any          
individual of any right1 procedure1 or  
remedy provided or protected under this 
subsection2 or  7ii7 coerce or          
intimidate any individual regarding the 
exercise1 or attempt to exercise1 such  
right4  7,b7 ,opposition to unlawful    
policies or practices ,a skilled nursing
 facility may not retaliate or          
discriminate against any individual for 
opposing any policy1 practice1 or action
 of the facility which is alleged to    
violate1 breach1 or fail to comply with 
any provision of the minimum nurse      
staffing requirements of clause 7ii7 of 
subsection 7b77#d77;,c74  7,c7          
,prohibition on interference with       
protected communications ,a skilled     
nursing facility may not make1 adopt1 or
 enforce any rule1 regulation1 policy1  
or practice which in any manner directly
 or indirectly prohibits1 impedes1 or   
discourages a nurse from1 or            

intimidates1 coerces1 or induces a nurse
 regarding1 engaging in free speech     
activities or disclosing information as 
provided under this subsection4  7,d7   
,prohibition on interference with       
collective action ,a skilled nursing    
facility may not in any way interfere   
with the rights of nurses to organize1  
bargain collectively1 and engage in     
concerted activity under section #g of  
the ,national ,labor ,relations ,act    
7#bi ,u4,s4,c4 #aeg74  7#i7 ,notice ,a  
skilled nursing facility shall post in  
an appropriate location in each unit a  
conspicuous notice1 in a form specified 
by the ,secretary1 that--  7,a7 explains
 the rights of nurses1 residents1 and   
other individuals under this subsection2
  7,b7 includes a statement that a      
nurse1 resident1 or other individual may
 file a complaint with the ,secretary   
against the facility for a violation of 
a requirement or a prohibition of this  
subsection2 and  7,c7 provides          
instructions on how to file such a      

complaint4  7#aj7 ,enforcement  7,a7 ,in
 general ,the ,secretary shall enforce  
the requirements and prohibitions of    
this subsection in accordance with this 
paragraph4  7,b7 ,procedures for        
receiving and investigating complaints  
,the ,secretary shall establish         
procedures under which-- 7i7 any        
individual may file a complaint alleging
 that a skilled nursing facility has    
violated a requirement or a prohibition 
of this subsection2 and  7ii7 any such  
complaint shall be investigated by the  
,secretary4  7,c7 ,remedies ,if the     
,secretary determines that a skilled    
nursing facility has violated a         
requirement or prohibition of this      
subsection1 the ,secretary--  7i7 shall 
require the facility to establish a     
corrective action plan to prevent the   
recurrence of such violation2 and  7ii7 
may impose civil money penalties as     
described in subparagraph 7,d74  7,d7   
,civil penalties  7i7 ,in general ,in   
addition to any other penalties         

prescribed by law1 the ,secretary may   
impose civil penalties as follows3  7,i7
 ,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--  7aa7 not more than  
#be1jjj for the first knowing violation 
of this subsection by such facility2 and
  7bb7 not more than #ej1jjj for any    
subsequent knowing violation of this    
subsection by such facility4  7,,ii7    
,individual liability ,the ,secretary   
may impose on an individual who-- 7aa7  
is employed by a skilled nursing        
facility2 and  7bb7 is found by the     
,secretary to have knowingly violated   
this subsection on behalf of the        
facility1  a civil money penalty of not 
more than #bj1jjj for each such         
violation by the individual4  7ii7      
,procedures ,the provisions of section  
#aabh;,a of the ,social ,security ,act  
7other than subsections 7a7 and 7b77    
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 #aabh;,a4  7,e7 ,public notice  
of violations  7i7 ,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 subsection1 the violation for
 which such penalty was imposed1 and    
such additional information as the      
,secretary determines appropriate4  7ii7
 ,change of ownership ,with respect to a
 skilled nursing facility that had a    
change of ownership1 as determined by   
the ,secretary1 penalties imposed on the
 facility while under previous ownership
 shall no longer be published by the    
,secretary pursuant to clause 7i7 after 
the #a-year period beginning on the date
 of such change of ownership4  7,f7 ,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 7ii7 of          
subsection 7b77#d77;,c74  7#aa7 ,nurse  
defined ,in this subsection1 the term   
nurse means a registered professional   
nurse1 a licensed practical nurse1 and a
 nurse aide4  4  7b7 ,medicaid ,section 
#aiai of the ,social ,security ,act 7#db
 ,u4,s4,c4 #acifr7 is amended by adding 
at the end the following new subsection3
  7k7 ,whistleblower and resident       
protections  7#a7 ,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 located1 to provide nursing 
care in the exclusive interests of the  
residents of the facility1 and to act as
 the residents' advocate4  7#b7         
,objection to or refusal of work        

assignment ,a nurse may object to1 or   
refuse to participate in1 any activity1 
policy1 practice1 assignment1 or task   
7referred to in this subsection as a    
work assignment7 if--  7,a7 the nurse   
reasonably believes such work assignment
 to be in violation of the minimum nurse
 staffing requirements of clause 7ii7 of
 subsection 7b77#d77;,c72 or  7,b7 the  
nurse reasonably believes that the nurse
 is not prepared by education1 training1
 or experience to perform or comply with
 such work assignment without           
compromising the safety of a resident or
 jeopardizing the license of the nurse4 
7#c7 ,retaliation for objection to or   
refusal of work assignment barred  7,a7 
,no discharge1 discrimination1 or       
retaliation ,no nursing facility may    
discharge1 retaliate1 discriminate1 or  
otherwise take adverse action in any    
manner with respect to any aspect of a  
nurse's employment with the facility1   
including discharge1 promotion1         
compensation1 or terms1 conditions1 or  

privileges of employment1 based on the  
nurse's objection to1 or refusal of1 a  
work assignment under paragraph 7#b74   
7,b7 ,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 to1 or refusal
 of1 a work assignment under paragraph  
7#b74  7#d7 ,cause of action ,any nurse 
7or a collective bargaining             
representative or legal representative  
of such nurse7 against whom a nursing   
facility has taken an adverse action in 
violation of paragraph 7#c77;,a71 or    
against whom such facility has filed a  
complaint or report in violation of     
paragraph 7#c77;,b71 may 7without regard
 to whether a complaint has been filed  
under paragraph 7#e7 or 7#aj77;,b77     
bring a cause of action in an           
appropriate district court of the       
,united ,states4 ,the legal burdens of  
proof specified in section #abba7;e7 of 
title #e1 ,united ,states ,code1 shall  

be controlling for the purposes of any  
cause of action brought under this      
paragraph4 ,a nurse who prevails on the 
cause of action may be entitled to one  
or more of the following3  7,a7         
,reinstatement4  7,b7 ,reimbursement of 
lost wages1 compensation1 and benefits4 
7,c7 ,attorneys' fees4  7,d7 ,court     
costs4  7,e7 ,other damages4  7#e7      
,complaint to ,secretary ,any individual
 may file a complaint with the          
,secretary against a nursing facility   
that violates a requirement described in
 paragraph 7#c74 ,for any complaint     
filed1 the ,secretary shall--  7,a7     
receive and investigate the complaint2  
7,b7 determine whether a violation of   
such paragraph1 as alleged in the       
complaint1 has occurred2 and  7,c7 in   
the case that the ,secretary determines 
that such a violation has occurred1     
issue an order that the complaining     
individual may not suffer any adverse   
action prohibited by paragraph 7#c7 or  
7#g74  7#f7 ,toll-,free telephone number

  7,a7 ,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 7ii7 of 
subsection 7b77#d77;,c7 and to receive  
reports of violations of such           
requirements4  7,b7 ,notice to residents
 ,a nursing facility shall provide each 
resident admitted to the facility with  
the telephone number of the hotline     
described in subparagraph 7,a7 and give 
notice to each such resident that such  
hotline may be used to report inadequate
 staffing or care4  7#g7 ,protection for
 reporting  7,a7 ,prohibition on        
retaliation or discrimination ,a nursing
 facility may not retaliate or          
discriminate in any manner against any  
resident1 employee1 or contract employee
 of the facility1 or any other          
individual1 on the basis that such      
resident1 employee1 contract employee1  
or individual 7individually or in       
conjunction with another individual7    

has1 in good faith--  7i7 presented a   
grievance or complaint2  7ii7 initiated 
or cooperated in any investigation or   
proceeding of any governmental entity1  
regulatory agency1 or private           
accreditation body2  7iii7 made a civil 
claim or demand2 or  7iv7 filed an      
action relating to the care1 services1  
or conditions of the facility4  7,b7    
,good faith defined ,for purposes of    
this paragraph1 an individual shall be  
deemed to be acting in good faith if the
 individual reasonably believes--  7i7  
the information reported or disclosed is
 true2 and  7ii7 a violation of the     
minimum nurse staffing requirements of  
clause 7ii7 of subsection 7b77#d77;,c7  
has occurred or may occur4  7#h7        
,prohibition on interference with rights
  7,a7 ,exercise of rights ,a nursing   
facility may not-- 7i7 interfere with1  
restrain1 or deny the exercise1 or      
attempt to exercise1 by any individual  
of any right1 procedure1 or remedy      
provided or protected under this        

subsection2 or  7ii7 coerce or          
intimidate any individual regarding the 
exercise1 or attempt to exercise1 such  
right4  7,b7 ,opposition to unlawful    
policies or practices ,a nursing        
facility may not retaliate or           
discriminate against any individual for 
opposing any policy1 practice1 or action
 of the facility which is alleged to    
violate1 breach1 or fail to comply with 
any provision of the minimum nurse      
staffing requirements of clause 7ii7 of 
subsection 7b77#d77;,c74  7,c7          
,prohibition on interference with       
protected communications ,a nursing     
facility may not make1 adopt1 or enforce
 any rule1 regulation1 policy1 or       
practice which in any manner directly or
 indirectly prohibits1 impedes1 or      
discourages a nurse from1 or            
intimidates1 coerces1 or induces a nurse
 regarding1 engaging in free speech     
activities or disclosing information as 
provided under this subsection4  7,d7   
,prohibition on interference with       

collective action ,a nursing facility   
may not in any way interfere with the   
rights of nurses to organize1 bargain   
collectively1 and engage in concerted   
activity under section #g of the        
,national ,labor ,relations ,act 7#bi   
,u4,s4,c4 #aeg74  7#i7 ,notice ,a       
nursing facility shall post in an       
appropriate location in each unit a     
conspicuous notice1 in a form specified 
by the ,secretary1 that--  7,a7 explains
 the rights of nurses1 residents1 and   
other individuals under this subsection2
  7,b7 includes a statement that a      
nurse1 resident1 or other individual may
 file a complaint with the ,secretary   
against the facility for a violation of 
a requirement or a prohibition of this  
subsection2 and  7,c7 provides          
instructions on how to file such a      
complaint4  7#aj7 ,enforcement  7,a7 ,in
 general ,the ,secretary shall enforce  
the requirements and prohibitions of    
this subsection in accordance with this 
paragraph4  7,b7 ,procedures for        

receiving and investigating complaints  
,the ,secretary shall establish         
procedures under which-- 7i7 any        
individual may file a complaint alleging
 that a nursing facility has violated a 
requirement or a prohibition of this    
subsection2 and  7ii7 any such complaint
 shall be investigated by the           
,secretary4  7,c7 ,remedies ,if the     
,secretary determines that a nursing    
facility has violated a requirement or  
prohibition of this subsection1 the     
,secretary--  7i7 shall require the     
facility to establish a corrective      
action plan to prevent the recurrence of
 such violation2 and  7ii7 may impose   
civil money penalties as described in   
subparagraph 7,d74  7,d7 ,civil         
penalties  7i7 ,in general ,in addition 
to any other penalties prescribed by    
law1 the ,secretary may impose civil    
penalties as follows3  7,i7 ,nursing    
facility liability ,the ,secretary may  
impose on a nursing facility found to be
 in violation of this subsection a civil

 money penalty of--  7aa7 not more than 
#be1jjj for the first knowing violation 
of this subsection by such facility2 and
  7bb7 not more than #ej1jjj for any    
subsequent knowing violation of this    
subsection by such facility4  7,,ii7    
,individual liability ,the ,secretary   
may impose on an individual who-- 7aa7  
is employed by a nursing facility2 and  
7bb7 is found by the ,secretary to have 
knowingly violated this subsection on   
behalf of the facility1  a civil money  
penalty of not more than #bj1jjj for    
each such violation by the individual4  
7ii7 ,procedures ,the provisions of     
section #aabh;,a of the ,social         
,security ,act 7other than subsections  
7a7 and 7b77 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 #aabh;,a4 
7,e7 ,public notice of violations  7i7  
,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     
subsection1 the violation for which such
 penalty was imposed1 and such          
additional information as the ,secretary
 determines appropriate4  7ii7 ,change  
of ownership ,with respect to a nursing 
facility that had a change of ownership1
 as determined by the ,secretary1       
penalties imposed on the facility while 
under previous ownership shall no longer
 be published by the ,secretary pursuant
 to clause 7i7 after the #a-year period 
beginning on the date of such change of 
ownership4  7,f7 ,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   
7ii7 of subsection 7b77#d77;,c74  7#aa7 
,nurse defined ,in this subsection1 the 
term nurse means a registered           

professional nurse1 a licensed practical
 nurse1 and a nurse aide4  4  7c7       
,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 assignments1           
complaints1 retaliations and other      
adverse actions1 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 enactment4  
#g4 ,prohibiting pre-dispute arbitration
 agreements  7a7 ,medicare ,section     
#ahai7;c7 of the ,social ,security ,act 
7#db ,u4,s4,c4 #acie;i-#c7;c77 is       
amended by adding at the end the        
following new paragraph3  7#g7          
,prohibition on use of pre-dispute      
arbitration agreements  7,a7 ,in general
 ,a skilled nursing facility may not    
require1 solicit1 accept1 or move to    
enforce a pre-dispute arbitration       

agreement from or on behalf of any      
resident1 whether the agreement is made 
before1 during1 or after the resident's 
admission to the facility1 or from or on
 behalf of any employee1 or contract    
employee of the facility1 or any other  
individual if such individual is alleged
 to be engaged in conduct protected     
under subsection 7k74  7,b7 ,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 resident4  7,c7 
,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 facility1 without  
regard to whether the agreement was made
 prior to or after the effective date of
 this paragraph4  7,d7 ,definition of   
pre-dispute arbitration agreement ,in   
this paragraph1 the term pre-dispute    
arbitration agreement means any         

agreement to arbitrate a dispute when   
the dispute has arisen after such       
agreement has been made4  7,e7 ,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 jurisdiction1 rather than 
an arbitrator1 without regard to whether
 the party opposing arbitration         
challenges such agreement specifically  
or in conjunction with any other term of
 the contract containing such agreement4
  4  7b7 ,medicaid  7#a7 ,home and      
community-based services and home health
 care services ,section #aiae of the    
,social ,security ,act 7#db ,u4,s4,c4   
#acifn7 is amended by adding at the end 
the following new subsection3  7m7      
,prohibiting pre-,dispute arbitration   
agreements  7#a7 ,in general ,for home  
and community-based services or home    
health care services provided under a   
waiver under this section1 section      
#aijb7;a77#aj77;,d71 or any other       

provision authorizing the provision of  
home and community-based services or    
home health care services under this    
title1 the provider of such services    
7and any employee1 agent1 related       
entity1 or affiliate of such provider7  
shall not require1 solicit1 or accept a 
pre-dispute arbitration agreement from  
or on behalf of any individual receiving
 such services1 whether the agreement is
 made before1 during1 or after the first
 date on which services are received1 or
 from or on behalf of any employee1 or  
contract employee of the provider1 or   
any other individual if such individual 
is alleged to be engaged in conduct     
protected under section #aiai7k74 ,a    
pre-dispute arbitration agreement       
between such a provider 7or entity or   
person7 and an individual receiving     
services 7or who formerly received      
services7 shall not be valid or         
enforceable1 without regard to whether  
such agreement was made prior to the    
effective date of this subsection4  7#b7

 ,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 made4  7#c7 ,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 jurisdiction1 rather than 
an arbitrator1 without regard to whether
 the party opposing arbitration         
challenges such agreement specifically  
or in conjunction with any other term of
 the contract containing such agreement4
  4  7#b7 ,nursing facilities ,section  
#aiai7;c7 of the ,social ,security ,act 
7#db ,u4,s4,c4 #acifr7c77 is amended by 
adding at the end the following new     
paragraph3  7#i7 ,prohibition on use of 
pre-dispute arbitration agreements  7,a7
 ,in general ,a nursing facility may not
 require1 solicit1 accept1 or move to   
enforce a pre-dispute arbitration       

agreement from or on behalf of any      
resident1 whether the agreement is made 
before1 during1 or after the resident's 
admission to the facility1 or from or on
 behalf of any employee1 or contract    
employee of the facility1 or any other  
individual if such individual is alleged
 to be engaged in conduct protected     
under subsection 7k74  7,b7 ,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 resident4  7,c7 ,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
 facility1 without regard to whether the
 agreement was made prior to or after   
the effective date of this paragraph4   
7,d7 ,definition of pre-dispute         
arbitration agreement ,in this          
paragraph1 the term pre-dispute         
arbitration agreement means any         

agreement to arbitrate a dispute when   
the dispute has arisen after such       
agreement has been made4  7,e7 ,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 jurisdiction1 rather than 
an arbitrator1 without regard to whether
 the party opposing arbitration         
challenges such agreement specifically  
or in conjunction with any other term of
 the contract containing such agreement4
  4  #h4 ,standardized protocol for     
obtaining informed consent from         
residents prior to prescribing          
psychotropic drugs  7a7 ,standardized   
protocol  7#a7 ,skilled nursing         
facilities ,section #ahai7;b7 of the    
,social ,security ,act 7#db ,u4,s4,c4   
#acie;i-#c7;b77 is amended by adding at 
the end the following new paragraph3    
7#i7 ,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  7,a7 ,protocol ,not    
later than the date that is one year    
after the date of the enactment of this 
paragraph1 the ,secretary1 taking into  
account the results of the study        
conducted by the ,comptroller ,general  
of the ,united ,states under section    
#h7;a77#c7 of the ,quality ,care for    
,nursing ,home ,residents ,act of #bjai 
and in consultation with stakeholder    
groups 7including residents of skilled  
nursing facilities1 family members of   
such residents1 advocates for such      
residents1 long-term care ombudsmen1 and
 providers71 shall develop a            
standardized protocol for skilled       
nursing facilities to obtain written    
informed consent1 in accordance with    
this paragraph1 from a resident 7or1 if 
applicable1 the resident's designated   
health care agent or other surrogate    
under ,state law or regulation7 prior to
 prescribing a psychotropic drug to the 

resident for a use not approved by the  
,food and ,drug ,administration4  7,b7  
,requirements ,the standardized protocol
 developed under subparagraph 7,a7 shall
 include the following3 7i7 ,a          
requirement1 with respect to a resident1
 that--  7,i7 the facility1 with the    
involvement of the prescriber1 inform   
the resident 7or1 if applicable1 the    
resident's designated health care agent 
or other surrogate under ,state law or  
regulation7 of--  7aa7 possible side    
effects and risks associated with the   
psychotropic drug1 including the mention
 of any black box warning2  7bb7        
treatment modalities that were attempted
 prior to the use of the psychotropic   
drug2 and  7cc7 any other information   
the ,secretary determines appropriate2  
7,,ii7 the resident 7or1 if applicable1 
the resident's designated health care   
agent or other surrogate under ,state   
law or regulation7 provide written      
informed consent to the administration  
of the psychotropic drug2 and  7,,iii7  

the administration of the psychotropic  
drug is in accordance with any plan of  
care that the resident has in place1    
including non-pharmacological           
interventions as appropriate that can   
effectively address underlying medical  
and environmental causes of behavioral  
disorders4  7ii7 ,an alternative        
protocol for obtaining such written     
informed consent-- 7,i7 in the case of  
emergencies2 and  7,,ii7 in the absence 
of a clearly identified designated      
health care agent or other surrogate    
under ,state law or regulation4  7iii7  
,other items determined appropriate by  
the ,secretary4  7,c7 ,timing of        
informed consent ,under the standardized
 protocol1 a skilled nursing facility   
shall obtain the written informed       
consent described in subparagraph 7,a71 
with respect to a psychotropic drug and 
a resident of the facility--  7i7 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 facility2 and  7ii7 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 place4  7,d7 ,compliance ,effective  
beginning on the date that is one year  
and #ahj days after the date of the     
enactment of this paragraph1 a skilled  
nursing facility shall comply with the  
standardized protocol developed under   
subparagraph 7,a74  7,e7 ,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 facilities4  4  7#b7       
,nursing facilities ,section #aiai7;b7  
of the ,social ,security ,act 7#db      
,u4,s4,c4 #acifr7b77 is amended by      
adding at the end the following new     
paragraph3  7#i7 ,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  7,a7 ,protocol ,not    
later than the date that is one year    
after the date of the enactment of this 
paragraph1 the ,secretary1 taking into  
account the results of the study        
conducted by the ,comptroller ,general  
of the ,united ,states under section    
#h7;a77#c7 of the ,quality ,care for    
,nursing ,home ,residents ,act of #bjai 
and in consultation with stakeholder    
groups 7including residents of skilled  
nursing facilities1 family members of   
such residents1 advocates for such      
residents1 long-term care ombudsmen1 and
 providers71 shall develop a            
standardized protocol for nursing       
facilities to obtain written informed   
consent1 in accordance with this        
paragraph1 from a resident 7or1 if      
applicable1 the resident's designated   
health care agent or other surrogate    
under ,state law or regulation7 prior to

 prescribing a psychotropic drug to the 
resident for a use not approved by the  
,food and ,drug ,administration4  7,b7  
,requirements ,the standardized protocol
 developed under subparagraph 7,a7 shall
 include the following3 7i7 ,a          
requirement1 with respect to a resident1
 that--  7,i7 the facility1 with the    
involvement of the prescriber1 inform   
the resident 7or1 if applicable1 the    
resident's designated health care agent 
or other surrogate under ,state law or  
regulation7 of--  7aa7 possible side    
effects and risks associated with the   
psychotropic drug1 including the mention
 of any black box warning2  7bb7        
treatment modalities that were attempted
 prior to the use of the psychotropic   
drug2 and  7cc7 any other information   
the ,secretary determines appropriate2  
7,,ii7 the resident 7or1 if applicable1 
the resident's designated health care   
agent or other surrogate under ,state   
law or regulation7 provide written      
informed consent to the administration  

of the psychotropic drug2 and  7,,iii7  
the administration of the psychotropic  
drug is in accordance with any plan of  
care that the resident has in place1    
including non-pharmacological           
interventions as appropriate that can   
effectively address underlying medical  
and environmental causes of behavioral  
disorders4  7ii7 ,an alternative        
protocol for obtaining such written     
informed consent-- 7,i7 in the case of  
emergencies2 and  7,,ii7 in the absence 
of a clearly identified designated      
health care agent or other surrogate    
under ,state law or regulation4  7iii7  
,other items determined appropriate by  
the ,secretary4  7,c7 ,timing of        
informed consent ,under the standardized
 protocol1 a nursing facility shall     
obtain the written informed consent     
described in subparagraph 7,a71 with    
respect to a psychotropic drug and a    
resident of the facility--  7i7 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 facility2 and  7ii7 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 place4  7,d7 ,compliance ,effective  
beginning on the date that is one year  
and #ahj days after the date of the     
enactment of this paragraph1 a nursing  
facility shall comply with the          
standardized protocol developed under   
subparagraph 7,a74  7,e7 ,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 facilities4  4  7#c7 ,,gao 
study and report on informed consent    
laws with respect to prescribing of     
psychotropic drugs  7,a7 ,study ,the    
,comptroller ,general of the ,united    
,states 7in this paragraph referred to  

as the ,comptroller ,general7 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 adults4 ,the study shall include  
an analysis as to whether in the case of
 ,states that have not enacted such     
informed consent laws1 such ,states have
 developed other mechanisms to guide    
appropriate prescribing of psychotropic 
drugs in older adults with dementia4    
7,b7 ,report ,not later than #ahj days  
after the date of enactment of this     
,act1 the ,comptroller ,general shall   
submit to the ,secretary of ,health and 
,human ,services1 the ,committees on    
,energy and ,commerce and ,ways and     
,means of the ,house of                 
,representatives1 and the ,committee on 
,finance of the ,senate a report        
containing the results of the study     

conducted under subparagraph 7,a71      
together with such recommendations as   
the ,comptroller ,general determines    
appropriate4  7b7 ,development of       
measure of utilization of psychotropic  
drugs for inclusion on ,nursing ,home   
,compare website  7#a7 ,medicare        
,section #ahai7;i7 of the ,social       
,security ,act 7#db ,u4,s4,c4           
#acie;i-#c7;i77 is amended-- 7,a7 by    
redesignating paragraph 7#c7 as         
paragraph 7#d72 and  7,b7 by inserting  
after paragraph 7#b7 the following new  
paragraph3  7#c7 ,development of measure
 of utilization of psychotropic drugs   
7,a7 ,in general ,not later than the    
date that is one year after the date of 
the enactment of this paragraph1 the    
,secretary shall include a measure of   
the utilization of psychotropic drugs   
for each skilled nursing facility for   
inclusion on such website 7or a         
successor website7 as part of the       
quality measures or health inspections  
measures1 or both such measures1 under  

the ,five-,star ,quality ,rating ,system
 established by the ,administrator of   
the ,centers for ,medicare  ,medicaid   
,services4  7,b7 ,considerations ,in    
developing the measure under            
subparagraph 7,a71 the ,secretary shall 
take into account special patient       
populations1 special care units1        
appropriate diagnoses1 and other        
factors1 as determined appropriate by   
the ,secretary4  4  7#b7 ,medicaid      
,section #aiai7;i7 of the ,social       
,security ,act 7#db ,u4,s4,c4 #acifr7i77
 is amended-- 7,a7 by redesignating     
paragraph 7#c7 as paragraph 7#d72 and   
7,b7 by inserting after paragraph 7#b7  
the following new paragraph3  7#c7      
,development of measure of utilization  
of psychotropic drugs  7,a7 ,in general 
,not later than the date that is one    
year after the date of the enactment of 
this paragraph1 the ,secretary shall    
include a measure of the utilization of 
psychotropic drugs for each nursing     
facility for inclusion on such website  

7or a successor website7 as part of the 
quality measures or health inspections  
measures1 or both such measures1 under  
the ,five-,star ,quality ,rating ,system
 established by the ,administrator of   
the ,centers for ,medicare  ,medicaid   
,services4  7,b7 ,considerations ,in    
developing the measure under            
subparagraph 7,a71 the ,secretary shall 
take into account special patient       
populations1 special care units1        
appropriate diagnoses1 and other        
factors1 as determined appropriate by   
the ,secretary4  4