,i #aafth ,,congress #b;d ,session ,h4 ,r4 #ijba ,,in ,,the ,,house ,,of ,,representatives ,december #ag1 #bjbj,mr4 ,pascrell 7for himself1 ,mr4 ,kelly of ,pennsylvania1 ,ms4 ,eshoo1 and ,mr4 ,mc,kinley7 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 modernize ,federal nursing home protections and to enhance care quality and transparency for nursing home residents and their families4 #a4 ,short title ,this ,act may be cited as the ,nursing ,home ,reform ,modernization ,act of #bjbj4 #b4 ,improvements to nursing facilities under the ,medicare and ,medicaid programs 7a7 ,advisory ,council on ,skilled ,nursing ,facility ,rankings under ,medicare and ,nursing ,facility ,rankings under ,medicaid 7#a7 ,establishment ,not later than #a year after the date of enactment of this ,act1 the ,secretary of ,health and ,human ,services shall establish the ,advisory ,council on ,skilled ,nursing ,facility ,rankings under ,medicare and ,nursing ,facility ,rankings under ,medicaid 7in this subsection referred to as the ,advisory ,council74 7#b7 ,membership ,the ,secretary shall ensure that the membership of the ,advisory ,council includes equal representation from the following3 7,a7 ,consumers with nursing home experience1 including adults age #fe and older1 individuals with disabilities1 family caregivers1 and their advocates4 7,b7 ,skilled nursing facilities and nursing facilities1 including non-profit facilities4 7,c7 ,academics with expertise in nursing home oversight4 7,d7 ,health professionals with nursing home experience1 such as physicians1 nurses1 pharmacists1 certified nursing assistants1 and direct care professionals4 7,e7 ,professionals with expertise in quality measurement4 7,f7 ,professionals with expertise in emergency management4 7,g7 ,state surveying agencies4 7,h7 ,state long-term care ombudsman programs4 7,i7 ,the ,medicare ,payment ,advisory ,commission4 7,j7 ,the ,medicaid and ,,chip ,payment and ,access ,commission4 7,k7 ,the ,centers for ,medicare ,medicaid ,services4 7,l7 ,other representatives as the ,secretary determines appropriate4 7#c7 ,duties 7,a7 ,study ,the ,advisory ,council shall conduct a study of processes for ranking skilled nursing facilities and nursing facilities under paragraph 7#i7 of section #ahai7;f7 of the ,social ,security ,act1 as added by subsection 7b77#a7 and under paragraph 7#aa7 of section #aiai7;f7 of such ,act1 as added by subsection 7c77#a74 ,such study shall include an analysis of-- 7i7 which available1 verifiable data sources and measures are best for appropriately designating facilities in-- 7,i7 the high-rated facility program under paragraph 7#aj7 of such section #ahai7;f7 and under paragraph 7#ab7 of such section #aiai7;f72 and 7,,ii7 the low-rated facility program under paragraph 7#h7 of such section #ahai7;f7 and under paragraph 7#aj7 of such section #aiai7;f72 7ii7 the appropriate frequency with which to update the rankings for the high-rated and low-rated facility programs described in clause 7i72 7iii7 how best to ensure that skilled nursing facilities and nursing facilities appropriately report adverse events2 7iv7 how surveyors can clearly provide the rationale for giving deficiencies to such skilled nursing facilities and nursing facilities and how this can be done in a timely manner2 7v7 how to manage suspensions from the high-rated facility program described in clause 7i77,i7 and the need for additional consumer protections to administer such high-rated facility program2 7vi7 the availability or potential development of1 or modifications to1 measures or verifiable data sources on topics1 including avoidable hospital readmissions1 emergency room visits1 risk-adjusted mortality1 discharges to the community1 involuntary discharges1 situations involving the inappropriate administration of medications by a facility1 and emergency management2 and 7vii7 the development of1 or modifications to1 data collection1 verifiable data sources1 and potential measures to assess the financial stability of a facility4 7,b7 ,findings and recommendations 7i7 ,in general ,not later than #b years after the date of enactment of this ,act1 the ,advisory ,council shall submit to the ,secretary the findings of the ,advisory ,council under the study conducted under subparagraph 7,a71 together with recommendations for such legislation and administrative action as the ,advisory ,council determines appropriate4 7ii7 ,public availability ,upon receiving the findings and recommendations under clause 7i71 the ,secretary shall make the findings and recommendations available to the public on the internet website of the ,centers for ,medicare ,medicaid ,services4 7#d7 ,sunset ,the ,advisory ,council shall terminate upon the submission of the report to the ,secretary under paragraph 7#c77;,b77i74 7b7 ,medicare program revisions 7#a7 ,establishment of rankings and high-rated facility program 7,a7 ,in general ,section #ahai7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#c7;f77 is amended by adding at the end the following new paragraphs3 7#i7 ,ranking process 7,a7 ,process 7i7 ,establishment ,the ,secretary shall establish a process to rank skilled nursing facilities based on compliance with the applicable requirements of this ,act4 7ii7 ,data ,the process established under clause 7i7 shall include the use of at least the preceding #c years of health inspection data1 if appropriate1 and other data as determined appropriate by the ,secretary4 7iii7 ,findings and recommendations of the ,advisory ,council on ,skilled ,nursing ,facility ,rankings under ,medicare and ,nursing ,facility ,rankings under ,medicaid ,in establishing the process under clause 7i71 the ,secretary shall take into account the findings and recommendations of the ,advisory ,council that are submitted to the ,secretary under section #b7;a77#c77;,b77i7 of the ,nursing ,home ,reform ,modernization ,act of #bjbj4 7,b7 ,ranking 7i7 ,in general ,under the process established under subparagraph 7,a71 the ,secretary shall use the rankings of skilled nursing facilities to categorize facilities into highest and lowest groups for the purposes specified in clause 7ii74 7ii7 ,timing and use of rankings ,not later than #b years after the date the ,secretary receives the findings and recommendations described in subparagraph 7,a77iii71 the ,secretary shall use the rankings under clause 7i7 for purposes of carrying out-- 7,i7 the high-rated facility program under paragraph 7#aj72 and 7,,ii7 the low-rated facility program under paragraph 7#h74 7#aj7 ,high-rated facility program 7,a7 ,establishment 7i7 ,in general ,not later than #b years after the date the ,secretary receives the findings and recommendations described in paragraph 7#i77;,a77iii71 the ,secretary shall establish and implement a high-rated facility program to encourage and reward compliance with the requirements of this ,act4 7ii7 ,report ,in establishing the high-rated facility program1 the ,secretary shall take into account the findings and recommendations described in paragraph 7#i77;,a77iii74 7iii7 ,regulations ,the ,secretary shall establish the high-rated facility program under clause 7i7 through notice and comment rulemaking4 7,b7 ,designation ,under the high-rated facility program1 subject to subparagraph 7,d71 the ,secretary shall designate the highest rated skilled nursing facilities under the rankings under paragraph 7#i77;,b7 as high-rated skilled nursing facilities4 7,c7 ,distinction on ,nursing ,home ,compare website ,a skilled nursing facility that is designated as a high-rated skilled nursing facility under subparagraph 7,b7 shall receive a high-rated distinction on the official ,internet website of the ,federal ,government for comparing nursing homes pursuant to subsection 7i77#a77;,c74 7,d7 ,suspension of high-rated status 7i7 ,in general ,the ,secretary shall suspend a skilled nursing facility's designation under subparagraph 7,b7 if the ,secretary determines that there are circumstances warranting such suspension4 7ii7 ,circumstances ,in establishing the circumstances under clause 7i71 the ,secretary shall take into account-- 7,i7 findings from ,federal surveys and investigations2 7,,ii7 findings from ,state surveys conducted under subsection 7g77#b77;,a72 7,,iii7 findings from ,state investigations and surveys conducted under subsection 7g77#d71 including a high number of substantiated complaints1 the frequency and severity of substantiated complaints1 and how the complaints are handled by the facility2 7,,iv7 situations involving changes of ownership1 administration1 or management of a skilled nursing facility1 or the director of nursing2 7,v7 situations involving the inappropriate administration of medications by a facility2 7,,vi7 situations involving involuntary discharges of residents2 and 7,,vii7 other factors determined appropriate by the ,secretary4 7iii7 ,no reinstatement prior to next standard survey ,if a skilled nursing facility's designation is suspended under clause 7i71 such designation shall not be reinstated prior to a subsequent survey as specified under subsection 7g77#b77;,a77iii74 4 7,b7 ,assessment of high-rated designation in special surveys ,section #ahai7;g77#b77;,a77iii77,,ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#c7;g77#b77;,a77iii77,,ii77 is amended-- 7i7 by inserting 7or1 in the case of a facility that is designated as a high-rated skilled nursing facility under subsection 7f77#aj71 shall be conducted7 after may be conducted2 and 7ii7 by adding at the end the following new sentence3 ,on and after the date the ,secretary implements the high-rated facility program under subsection 7f77#aj71 any survey conducted1 pursuant to the preceding sentence1 of a facility that is designated as a high-rated skilled nursing facility under such subsection shall include an assessment of whether such designation should continue or be suspended under subparagraph 7,d7 of such subsection44 7#b7 ,improvements to the special focus facility program 7,a7 ,appropriate participation ,section #ahai7;f77#h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#c7;f77#h77 is amended-- 7i7 in subparagraph 7,a71 by striking ,the ,secretary and inserting ,subject to the succeeding provisions of this subsection1 the ,secretary2 and 7ii7 by adding at the end the following new subparagraph3 7,c7 ,appropriate participation ,not later than #a year after the date of enactment of the ,nursing ,home ,reform ,modernization ,act of #bjbj1 the ,secretary shall ensure that the number of facilities participating in the special focus facility program is not less than #c4e percent of all skilled nursing facilities4 4 7,b7 ,conversion of the special focus facility program to the low-rated facility program and additional requirements ,section #ahai7;f77#h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#c7;f77#h771 as amended by subparagraph 7,a71 is amended-- 7i7 in subparagraph 7,b71 by inserting the following before the period at the end3 7or1 on and after the date the ,secretary makes the conversion described in subparagraph 7,d71 at a frequency determined appropriate by the ,secretary 7but in no case less than once every #f months772 and 7ii7 by adding at the end the following new subparagraphs3 7,d7 ,conversion to the low-rated facility program 7i7 ,in general ,on the same date that the ,secretary implements the high-rated facility program under paragraph 7#aj71 the ,secretary shall convert the special focus facility program under this subsection to the low-rated facility program4 7ii7 ,regulations ,the ,secretary shall carry out the conversion under clause 7i7 through notice and comment rulemaking4 7iii7 ,additional requirements for the low-rated facility program ,in addition to the provisions that apply to the low-rated facility program through the conversion from the special focus facility program1 the succeeding provisions of this subsection shall also apply to the low-rated facility program4 7,e7 ,participation ,subject to the minimum participation requirement under subparagraph 7,c71 the ,secretary shall designate the lowest rated skilled nursing facilities under the rankings under paragraph 7#i77;,b7 for participation in the low-rated facility program4 7,f7 ,progressive enforcement actions ,the ,secretary1 in consultation with ,states1 shall utilize progressive enforcement actions1 of increasing severity1 to ensure facilities participating in the low-rated facility program meet the applicable requirements under this ,act4 7,g7 ,enforcement for patterns of deficiency ,the ,secretary may utilize enforcement actions specified in subsection 7h77#b7 to remedy patterns of deficiencies cited across multiple surveys4 7,h7 ,compliance assistance programs 7i7 ,on-site consultation and educational programming 7,i7 ,in general ,the ,secretary shall establish on-site consultation and educational programming for skilled nursing facilities participating in the low-rated facility program with respect to compliance with the applicable requirements under this ,act4 7,,ii7 ,entity ,the on-site consultation and educational programming described in subclause 7,i7 shall be carried out by quality improvement organizations under part ,b of title ,,xi or other independent organizations of a similar type that do not have conflicts of interest and are deemed appropriate by the ,secretary4 7,,iii7 ,required participation ,a skilled nursing facility participating in the low-rated facility program shall participate in any consultations and educational programming described in subclause 7,i7 conducted at the facility4 7ii7 ,consultation independent of enforcement 7,i7 ,in general ,subject to subclause 7,,ii71 on-site consultations and educational programming described in clause 7i7 shall be conducted independently of any enforcement activity4 7,,ii7 ,exception ,subclause 7,i7 shall not apply in the case where a triggering event at the skilled nursing facility is observed in the course of providing on-site consultations and educational programming described in clause 7i74 ,in establishing such on-site consultations and educational programming1 the ,secretary shall determine the triggering events for which the use of necessary enforcement actions is permitted notwithstanding the limitation under subclause 7,i74 ,such triggering events shall include events that are required to be reported under ,state and ,federal law and a pattern of deficiencies or problems that the quality improvement organization or other organization has identified for correction but which are consistently not corrected4 7,i7 ,public availability 7i7 ,in general ,the ,secretary shall ensure that a skilled nursing facility's participation in the low-rated facility program is publicly announced1 including to-- 7,i7 resident family councils2 7,,ii7 resident attending physicians2 7,,iii7 the ,state board responsible for the licensing of the skilled nursing facility administrator at the facility2 7,,iv7 ,state ,long-,term ,care ,ombudsman programs 7as described in section #gab7;a77#a7 of the ,older ,americans ,act of #aife72 and 7,v7 the community at large4 7ii7 ,written notification ,the ,secretary shall ensure that1 in the case of a skilled nursing facility that is participating in the low-rated facility program1 residents of such facility and family or legal representatives are furnished with individualized written notice of such participation4 ,such notice shall be provided to current residents and to new residents prior to admission4 7,j7 ,requirement for removal ,the ,secretary shall require that a skilled nursing facility show improvement prior to removal from the low-rated facility program4 4 7,c7 ,use of civil money penalties ,section #ahai7;h77#b77;,b77ii77,,iv77ff7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#c7;h77#b77;,b77ii77,,iv77ff77 is amended-- 7i7 by striking and facility improvement initiatives and inserting facility improvement initiatives2 and 7ii7 by inserting the following before the period at the end3 1 and1 on and after the date the ,secretary makes the conversion described in subsection 7f77#h77;,d71 consultation1 education1 and other activities to foster improvement and remedy root causes contributing to deficiencies cited across multiple surveys among facilities in the low-rated facility program under subsection 7f77#h74 7#c7 ,information on high-rated and low-rated facilities on ,nursing ,home ,compare ,medicare website ,section #ahai7;i77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#c7;i77#a77 is amended-- 7,a7 in subparagraph 7,a71 by adding at the end the following new clause3 7vi7 ,on and after the date the ,secretary implements the high-rated facility program under subsection 7f77#aj7 and makes the conversion under subsection 7f77#h77;,d71 consistent with subparagraph 7,c7-- 7,i7 for each skilled nursing facility that is designated as a high-rated skilled nursing facility under subsection 7f77#aj71 the date the facility was so designated2 and 7,,ii7 for each skilled nursing facility participating in the low-rated facility program under subsection 7f77#h71 the date the facility was identified for inclusion in such program4 2 and 7,b7 by adding at the end the following new subparagraphs3 7,c7 ,distinctions for high-rated and low-rated facilities ,on and after the date the ,secretary implements the high-rated facility program under subsection 7f77#aj7 and makes the conversion under subsection 7f77#h77;,d71 the ,secretary shall ensure that graphics1 including an appropriate explanation of such graphics1 are prominently displayed on the website described in subparagraph 7,a7 in order to distinguish each of the following3 7i7 ,skilled nursing facilities that are designated as high-rated skilled nursing facilities under subsection 7f77#aj74 7ii7 ,skilled nursing facilities that are participating in the low-rated facility program under subsection 7f77#h71 with information on facilities that have been placed in such program more than one time over the course of the last #aj years 7including the number of times such skilled nursing facilities have been placed in the program74 7,d7 ,focus groups and consumer testing ,in order to help limit confusion1 particularly among older adults1 individuals with disabilities1 and family caregivers1 the ,secretary shall utilize focus groups and other consumer testing methods prior to including the additional information under subparagraph 7,a77vi7 and implementing the distinctions under subparagraph 7,c74 4 7c7 ,medicaid program revisions 7#a7 ,establishment of rankings and high-rated facility program 7,a7 ,in general ,section #aiai7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr7f77 is amended by adding at the end the following new paragraphs3 7#aa7 ,ranking process 7,a7 ,process 7i7 ,establishment ,the ,secretary shall establish a process to rank nursing facilities based on compliance with the applicable requirements of this ,act4 7ii7 ,data ,the process established under clause 7i7 shall include the use of at least the preceding #c years of health inspection data1 if appropriate1 and other data as determined appropriate by the ,secretary4 7iii7 ,findings and recommendations of the ,advisory ,council on ,skilled ,nursing ,facility ,rankings under ,medicare and ,nursing ,facility ,rankings under ,medicaid ,in establishing the process under clause 7i71 the ,secretary shall take into account the findings and recommendations of the ,advisory ,council that are submitted to the ,secretary under section #b7;a77#c77;,b77i7 of the ,nursing ,home ,reform ,modernization ,act of #bjbj4 7,b7 ,ranking 7i7 ,in general ,under the process established under subparagraph 7,a71 the ,secretary shall use the rankings of nursing facilities to categorize facilities into highest and lowest groups for the purposes specified in clause 7ii74 7ii7 ,timing and use of rankings ,not later than #b years after the date the ,secretary receives the findings and recommendations described in subparagraph 7,a77iii71 the ,secretary shall use the rankings under clause 7i7 for purposes of carrying out-- 7,i7 the high-rated facility program under paragraph 7#ab72 and 7,,ii7 the low-rated facility program under paragraph 7#aj74 7#ab7 ,high-rated facility program 7,a7 ,establishment 7i7 ,in general ,not later than #b years after the date the ,secretary receives the findings and recommendations described in paragraph 7#aa77;,a77iii71 the ,secretary shall establish and implement a high-rated facility program to encourage and reward compliance with the requirements of this ,act4 7ii7 ,report ,in establishing the high-rated facility program1 the ,secretary shall take into account the findings and recommendations described in paragraph 7#aa77;,a77iii74 7iii7 ,regulations ,the ,secretary shall establish the high-rated facility program under clause 7i7 through notice and comment rulemaking4 7,b7 ,designation ,under the high-rated facility program1 subject to subparagraph 7,d71 the ,secretary shall designate the highest rated nursing facilities under the rankings under paragraph 7#aa77;,b7 as high-rated nursing facilities4 7,c7 ,distinction on ,nursing ,home ,compare website ,a nursing facility that is designated as a high-rated nursing facility under subparagraph 7,b7 shall receive a high-rated distinction on the official ,internet website of the ,federal ,government for comparing nursing homes pursuant to subsection 7i77#a77;,c74 7,d7 ,suspension of high-rated status 7i7 ,in general ,the ,secretary shall suspend a nursing facility's designation under subparagraph 7,b7 if the ,secretary determines that there are circumstances warranting such suspension4 7ii7 ,circumstances ,in establishing the circumstances under clause 7i71 the ,secretary shall take into account-- 7,i7 findings from ,federal surveys and investigations2 7,,ii7 findings from ,state surveys conducted under subsection 7g77#b77;,a72 7,,iii7 findings from ,state investigations and surveys conducted under subsection 7g77#d71 including a high number of substantiated complaints1 the frequency and severity of substantiated complaints1 and how the complaints are handled by the facility2 7,,iv7 situations involving changes of ownership1 administration1 or management of a nursing facility1 or the director of nursing2 7,v7 situations involving the inappropriate administration of medications by a facility2 7,,vi7 situations involving involuntary discharges of residents2 and 7,,vii7 other factors determined appropriate by the ,secretary4 7iii7 ,no reinstatement prior to next standard survey ,if a nursing facility's designation is suspended under clause 7i71 such designation shall not be reinstated prior to a subsequent survey as specified under subsection 7g77#b77;,a77iii74 4 7,b7 ,assessment of high-rated designation in special surveys ,section #aiai7;g77#b77;,a77iii77,,ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr7g77#b77;,a77iii77,,ii77 is amended-- 7i7 by inserting 7or1 in the case of a facility that is designated as a high-rated nursing facility under subsection 7f77#ab71 shall be conducted7 after may be conducted2 and 7ii7 by adding at the end the following new sentence3 ,on and after the date the ,secretary implements the high-rated facility program under subsection 7f77#ab71 any survey conducted1 pursuant to the preceding sentence1 of a facility that is designated as a high-rated nursing facility under such subsection shall include an assessment of whether such designation should continue or be suspended under subparagraph 7,d7 of such subsection44 7#b7 ,improvements to the special focus facility program 7,a7 ,appropriate participation ,section #aiai7;f77#aj7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acier7f77#aj77 is amended-- 7i7 in subparagraph 7,a71 by striking ,the ,secretary and inserting ,subject to the succeeding provisions of this subsection1 the ,secretary2 and 7ii7 by adding at the end the following new subparagraph3 7,c7 ,appropriate participation ,not later than #a year after the date of enactment of the ,nursing ,home ,reform ,modernization ,act of #bjbj1 the ,secretary shall ensure that the number of facilities participating in the special focus facility program is not less than #c4e percent of all nursing facilities4 4 7,b7 ,conversion of the special focus facility program to the low-rated facility program and additional requirements ,section #aiai7;f77#aj7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#c7;f77#aj771 as amended by subparagraph 7,a71 is amended-- 7i7 in subparagraph 7,b71 by inserting the following before the period at the end3 7or1 on and after the date the ,secretary makes the conversion described in subparagraph 7,d71 at a frequency determined appropriate by the ,secretary 7but in no case less than once every #f months772 and 7ii7 by adding at the end the following new subparagraphs3 7,d7 ,conversion to the low-rated facility program 7i7 ,in general ,on the same date that the ,secretary implements the high-rated facility program under paragraph 7#ab71 the ,secretary shall convert the special focus facility program under this subsection to the low-rated facility program4 7ii7 ,regulations ,the ,secretary shall carry out the conversion under clause 7i7 through notice and comment rulemaking4 7iii7 ,additional requirements for the low-rated facility program ,in addition to the provisions that apply to the low-rated facility program through the conversion from the special focus facility program1 the succeeding provisions of this subsection shall also apply to the low-rated facility program4 7,e7 ,participation ,subject to the minimum participation requirement under subparagraph 7,c71 the ,secretary shall designate the lowest rated nursing facilities under the rankings under paragraph 7#aa77;,b7 for participation in the low-rated facility program4 7,f7 ,progressive enforcement actions ,the ,secretary1 in consultation with ,states1 shall utilize progressive enforcement actions1 of increasing severity1 to ensure facilities participating in the low-rated facility program meet the applicable requirements under this ,act4 7,g7 ,enforcement for patterns of deficiency ,the ,secretary may utilize enforcement actions specified in subsection 7h77#b7 to remedy patterns of deficiencies cited across multiple surveys4 7,h7 ,compliance assistance programs 7i7 ,on-site consultation and educational programming 7,i7 ,in general ,the ,secretary shall establish on-site consultation and educational programming for nursing facilities participating in the low-rated facility program with respect to compliance with the applicable requirements under this ,act4 7,,ii7 ,entity ,the on-site consultation and educational programming described in subclause 7,i7 shall be carried out by quality improvement organizations under part ,b of title ,,xi or other independent organizations of a similar type that do not have conflicts of interest and are deemed appropriate by the ,secretary4 7,,iii7 ,required participation ,a nursing facility participating in the low-rated facility program shall participate in any consultations and educational programming described in subclause 7,i7 conducted at the facility4 7ii7 ,consultation independent of enforcement 7,i7 ,in general ,subject to subclause 7,,ii71 on-site consultations and educational programming described in clause 7i7 shall be conducted independently of any enforcement activity4 7,,ii7 ,exception ,subclause 7,i7 shall not apply in the case where a triggering event at the nursing facility is observed in the course of providing on-site consultations and educational programming described in clause 7i74 ,in establishing such on-site consultations and educational programming1 the ,secretary shall determine the triggering events for which the use of necessary enforcement actions is permitted notwithstanding the limitation under subclause 7,i74 ,such triggering events shall include events that are required to be reported under ,state and ,federal law and a pattern of deficiencies or problems that the quality improvement organization or other organization has identified for correction but which are consistently not corrected4 7,i7 ,public availability 7i7 ,in general ,the ,secretary shall ensure that a nursing facility's participation in the low-rated facility program is publicly announced1 including to-- 7,i7 resident family councils2 7,,ii7 resident attending physicians2 7,,iii7 the ,state board responsible for the licensing of the nursing facility administrator at the facility2 7,,iv7 ,state ,long-,term ,care ,ombudsman programs 7as described in section #gab7;a77#a7 of the ,older ,americans ,act of #aife72 and 7,v7 the community at large4 7ii7 ,written notification ,the ,secretary shall ensure that1 in the case of a nursing facility that is participating in the low-rated facility program1 residents of such facility and family or legal representatives are furnished with individualized written notice of such participation4 ,such notice shall be provided to current residents and to new residents prior to admission4 7,j7 ,requirement for removal ,the ,secretary shall require that a nursing facility show improvement prior to removal from the low-rated facility program4 4 7,c7 ,use of civil money penalties ,section #aiai7;h77#c77;,c77ii77,,iv77ff7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr7h77#c77;,c77ii77,,iv77ff77 is amended-- 7i7 by striking and facility improvement initiatives and inserting facility improvement initiatives2 and 7ii7 by inserting the following before the period at the end3 1 and1 on and after the date the ,secretary makes the conversion described in subsection 7f77#aj77;,d71 consultation1 education1 and other activities to foster improvement and remedy root causes contributing to deficiencies cited across multiple surveys among facilities in the low-rated facility program under subsection 7f77#aj74 7#c7 ,information on high-rated and low-rated facilities on ,nursing ,home ,compare ,medicare website ,section #aiai7;i77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr7i77#a77 is amended-- 7,a7 in subparagraph 7,a71 by adding at the end the following new clause3 7vi7 ,on and after the date the ,secretary implements the high-rated facility program under subsection 7f77#ab7 and makes the conversion under subsection 7f77#aj77;,d71 consistent with subparagraph 7,c7-- 7,i7 for each nursing facility that is designated as a high-rated nursing facility under subsection 7f77#ab71 the date the facility was so designated2 and 7,,ii7 for each nursing facility participating in the low-rated facility program under subsection 7f77#aj71 the date the facility was identified for inclusion in such program4 2 and 7,b7 by adding at the end the following new subparagraphs3 7,c7 ,distinctions for high-rated and low-rated facilities ,on and after the date the ,secretary implements the high-rated facility program under subsection 7f77#ab7 and makes the conversion under subsection 7f77#aj77;,d71 the ,secretary shall ensure that graphics1 including an appropriate explanation of such graphics1 are prominently displayed on the website described in subparagraph 7,a7 in order to distinguish each of the following3 7i7 ,nursing facilities that are designated as high-rated nursing facilities under subsection 7f77#ab74 7ii7 ,nursing facilities that are participating in the low-rated facility program under subsection 7f77#aj71 with information on facilities that have been placed in such program more than one time over the course of the last #aj years 7including the number of times such nursing facilities have been placed in the program74 7,d7 ,focus groups and consumer testing ,in order to help limit confusion1 particularly among older adults1 individuals with disabilities1 and family caregivers1 the ,secretary shall utilize focus groups and other consumer testing methods prior to including the additional information under subparagraph 7,a77vi7 and implementing the distinctions under subparagraph 7,c74 4 7d7 ,,gao study and report 7#a7 ,study ,the ,comptroller ,general of the ,united ,states 7in this section referred to as the ,comptroller ,general7 shall conduct a study on the quality of items and services furnished by skilled nursing facilities under title ,,xviii of the ,social ,security ,act and nursing facilities under title ,,xix of such ,act1 and such facilities' compliance with the applicable requirements under such titles4 ,such study shall include analysis of the following3 7,a7 ,the effectiveness of the low-rated facility program established under paragraph 7#h7 of section #ahai7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#c7;f771 as amended by subsection 7b77#b71 and under paragraph 7#aj7 of section #aiai7;f7 of such ,act 7#db ,u4,s4,c4 #acifr7f771 as amended by subsection 7c77#b74 7,b7 ,other areas determined appropriate by the ,comptroller ,general4 7#b7 ,report ,not later than #f years after the date of enactment of this ,act1 the ,comptroller ,general shall submit to the appropriate ,committees of ,congress a report containing the results of the study conducted under paragraph 7#a71 together with recommendations for such legislation and administrative action as the ,comptroller ,general determines appropriate4 7e7 ,rules of construction 7#a7 ,surveys ,nothing in the provisions of1 or the amendments made by1 this section shall be construed to allow the ,secretary to modify or deviate from-- 7,a7 a survey schedule that requires unannounced and unanticipated surveying of skilled nursing facilities under subsection 7g77#b77;,a77i7 of section #ahai of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#c7;g77 or under subsection 7g77#b77;,a77i7 of section #aiai of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr7g772 7,b7 the surveying frequency specified under subsection 7g77#b77;,a77iii7 of such section #ahai or under subsection 7g77#b77;,a77iii7 of such section #aiai2 or 7,c7 surveys and investigations as required under subsection 7g77#d7 of such section #ahai or under subsection 7g77#d7 of such section #aiai4 7#b7 ,accountability and ,state law ,nothing in the provisions of1 or the amendments made by1 this section shall be construed to impact the ability of a resident1 the family of a resident1 or a successor in interest to hold a skilled nursing facility or nursing facility accountable or change protections granted under ,state law4 #c4 ,definitions ,in this ,act3 7#a7 ,appropriate ,committees of ,congress ,the term appropriate ,committee of ,congress means-- 7,a7 the ,committee on ,finance of the ,senate2 7,b7 the ,committee on ,health1 ,education1 ,labor1 and ,pensions of the ,senate2 7,c7 the ,special ,committee on ,aging of the ,senate2 7,d7 the ,committee on ,ways and ,means of the ,house of ,representatives2 and 7,e7 the ,committee on ,energy and ,commerce of the ,house of ,representatives4 7#b7 ,nursing facility ,the term nursing facility has the meaning given that term in section #aiai7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr7a774 7#c7 ,skilled nursing facility ,the term skilled nursing facility has the meaning given that term in section #ahai7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#c7;a774 7#d7 ,secretary ,the term ,secretary means the ,secretary of ,health and ,human ,services4