,,ii  #aaf? ,,congress  #a/ ,session    
,s4 #bidc  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,novemb] #ba1 #bjai,mr4
 ,blum5?al 7= himself1 ,ms4 ,klobu*>1 & 
,mr4 ,book]7 introduc$ ! foll[+ bill2   
:i* 0 read twice & ref]r$ to !          
,committee on ,f9ance  ,a ,,bill  ,to   
am5d titles ,,xviii & ,,xix ( ! ,social 
,security ,act to revise m9imum nurse   
/aff+ requirem5ts = skill$ nurs+        
facilities "u ! ,m$ic>e program & =     
nurs+ facilities "u ! ,m$icaid program1 
& = o!r purposes4  #a4 ,%ort title ,?is 
,act may be cit$ z ! ,quality ,c>e =    
,nurs+ ,home ,resid5ts ,act ( #bjai4    
#b4 ,m9imum nurse /aff+ requirem5ts =   
skill$ nurs+ facilities "u ,m$ic>e      
program & nurs+ facilities "u ,m$icaid  
program  7a7 ,m$ic>e  7#a7 ,9 g5]al     
,subp>agraph 7,c7 ( section             
#ahai7;b77#d7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acie;i-#c7;b77#d77 is  
am5d$--  7,a7 9 clause 7i7-- 7i7 by     
am5d+ ! clause head+ to read z foll[s3  
,g5]al requirem5ts be=e #bjbj2 &  7ii7  

by /rik+ ,except z provid$ 9 clause     
7ii71 & ins]t+ ,except z provid$ 9      
clause 7iii71 ) respect to skill$ nurs+ 
facility s]vices provid$ be=e ,janu>y   
#a1 #bjbj12  7,b7 by r$esignat+ clause  
7ii7 z clause 7iii72 &  7,c7 by ins]t+  
aft] clause 7i7 ! foll[+ new clause3    
7ii7 ,g5]al requirem5ts aft] #bjai  7,i7
 ,9 g5]al ,) respect to skill$ nurs+    
facility s]vices provid$ on or aft]     
,janu>y #a1 #bjbj1 a skill$ nurs+       
facility mu/--  7aa7 provide nurs+      
s]vices t are suffici5t to meet ! nurs+ 
ne$s ( its resid5ts on a #bd-;h\r basis1
 to be divid$ into day %ifts1 ev5+      
%ifts1 & night %ifts2  7bb7 provide =   
m9imum nurse /aff+ levels ) respect to  
ea* su* %ift1 9 accordance ) ?is clause2
 &  7cc7 ensure t1 9 c>ry+ out items    
7aa7 & 7bb71 a total m9imum ( #d4a h\rs 
( c>e is provid$ p] resid5t p] day1 )   
#j4ge h\rs ( c>e ( su* total m9imum     
provid$ by a regi/]$ pr(essional nurse1 
#j4ed h\rs ( c>e ( su* total m9imum     
provid$ by a lic5s$ practical nurse1 &  

#b4ha h\rs ( c>e ( su* total m9imum     
provid$ by a nurse aide 7z def9$ 9      
p>agraph 7#e77;,f774  7,,ii7 ,day %ifts 
,) respect to a day %ift1 ! skill$ nurs+
 facility mu/ h-- 7aa7 at lea/ #a       
regi/]$ pr(essional nurse = e #bh       
resid5ts1 ) a m9imum ( #j4bi h\rs ( c>e 
provid$ p] resid5t dur+ ea* su* %ift2   
7bb7 at lea/ #a lic5s$ practical nurse =
 e #dj resid5ts1 ) a m9imum ( #j4bj h\rs
 ( c>e provid$ p] resid5t dur+ ea* su*  
%ift2 &  7cc7 at lea/ #a nurse aide 7z  
def9$ 9 p>agraph 7#e77;,f77 = e #g      
resid5ts1 ) a m9imum ( #a4ad h\rs ( c>e 
provid$ p] resid5t dur+ ea* su* %ift4   
7,,iii7 ,ev5+ %ifts ,) respect to an    
ev5+ %ift1 ! skill$ nurs+ facility mu/  
h-- 7aa7 at lea/ #a regi/]$ pr(essional 
nurse = e #cj resid5ts1 ) a m9imum (    
#j4bf h\rs ( c>e provid$ p] resid5t dur+
 ea* su* %ift2  7bb7 at lea/ #a lic5s$  
practical nurse = e #dj resid5ts1 ) a   
m9imum ( #j4bj h\rs ( c>e provid$ p]    
resid5t dur+ ea* su* %ift2 &  7cc7 at   
lea/ #a nurse aide 7z def9$ 9 p>agraph  

7#e77;,f77 = e #g resid5ts1 ) a m9imum (
 #a4ad h\rs ( c>e provid$ p] resid5t    
dur+ ea* su* %ift4  7,,iv7 ,night %ifts 
,) respect to a night %ift1 ! skill$    
nurs+ facility mu/ h-- 7aa7 at lea/ #a  
regi/]$ pr(essional nurse = e #dj       
resid5ts1 ) a m9imum ( #j4bj h\rs ( c>e 
provid$ p] resid5t dur+ su* %ift2  7bb7 
at lea/ #a lic5s$ practical nurse = e   
#ef resid5ts1 ) a m9imum ( #j4ad h\rs ( 
c>e provid$ p] resid5t dur+ su* %ift2 & 
7cc7 at lea/ #a nurse aide 7z def9$ 9   
p>agraph 7#e77;,f77 = e #ae resid5ts1 ) 
a m9imum ( #j4ec h\rs ( c>e provid$ p]  
resid5t dur+ su* %ift4  7,v7 ,secret>ial
 au?ority to e/abli% high] m9imum nurse 
/aff+ levels ,! ,secret>y may e/abli% & 
require skill$ nurs+ facilities 7or1 at 
! ,secret>y's discretion1 only skill$   
nurs+ facilities t h a high] p]c5tage ( 
resid5ts ) ext5sive c>e ne$s1 z det]m9$ 
by ! ,secret>y7 to provide = m9imum     
nurse /aff+ levels t are high] ?an !    
levels requir$ "u ?is clause4  7,,vi7   
,rule ( con/ruction reg>d+ ,/ate        

au?ority to e/abli% high] m9imum nurse  
/aff+ levels ,no?+ 9 ?is clause may be  
con/ru$ z prev5t+ a ,/ate f e/abli%+ or 
requir+ skill$ nurs+ facilities 9 !     
,/ate to provide = m9imum nurse /aff+   
levels t are high] ?an ! levels requir$ 
"u ?is clause4  7,,vii7 ,cl>ification ) 
respect to m9imum h\rs ( c>e provid$ p] 
resid5t requirem5ts ,9 comply+ ) !      
m9imum h\rs ( c>e provid$ p] resid5t    
requirem5ts "u ?is clause1 a skill$     
nurs+ facility may n c\nt any "t sp5t by
 a regi/]$ pr(essional nurse1 lic5s$    
practical nurse1 or nurse aide on       
adm9i/rative s]vices t[>ds compliance ) 
su* requirem5ts4  7,,viii7 ,def9itions  
,9 ?is clause3 7aa7 ,adm9i/rative       
s]vices ,! t]m adm9i/rative s]vices     
means food prep>ation1 h\sekeep+1       
laundry s]vices1 ma9t5ance s]vices1 &   
o!r nonc>egiv+-relat$ s]vices1 z det]m9$
 by ! ,secret>y4  7bb7 ,day %ift ,! t]m 
day %ift means1 ) respect to a day & a  
skill$ nurs+ facility1 an assign$ "w    
%ift t is a p]iod ( #h consecutive h\rs1

 beg9n+ n soon] ?an #f a4m4 9 ! "t zone 
9 :i* su* facility is locat$ & n lat]   
?an #h a4m4 9 su* "t zone4  7cc7 ,ev5+  
%ift ,! t]m ev5+ %ift means1 ) respect  
to a day & a skill$ nurs+ facility1 an  
assign$ "w %ift t is a p]iod ( #h       
consecutive h\rs1 beg9n+ n soon] ?an #b 
p4m4 9 ! "t zone 9 :i* su* facility is  
locat$ & n lat] ?an #d p4m4 9 su* "t    
zone4  7dd7 ,night %ift ,! t]m night    
%ift means1 ) respect to a day & a      
skill$ nurs+ facility1 an assign$ "w    
%ift t is a p]iod ( #h consecutive h\rs1
 beg9n+ n soon] ?an #aj p4m4 9 ! "t zone
 9 :i* su* facility is locat$ & n lat]  
?an midnight 9 su* "t zone4  4  7#b7    
,en=cem5t ,section #ahai7;h7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#acie;i-#c7;h77 is am5d$-- 7,a7 9       
p>agraph 7#a71 by /rik+ ,if a ,/ate     
f9ds1 on ! basis ( a /&>d & ins]t+      
,subject to p>agraph 7#g71 if a ,/ate   
f9ds1 on ! basis ( a /&>d2  7,b7 9      
p>agraph 7#b71 by /rik+ ,) respect to & 
ins]t+ ,subject to p>agraph 7#g71 )     

respect to2 &  7,c7 by add+ at ! end !  
foll[+ new p>agraph3  7#g7 ,special     
en=cem5t process ) respect to m9imum    
nurse /aff+ requirem5ts  7,a7 ,9 g5]al  
,if a ,/ate f9ds1 on ! basis ( a /&>d1  
ext5d$1 or p>tial ext5d$ survey "u      
subsection 7g77#b7 or o!rwise1 t a      
skill$ nurs+ facility does n meet !     
m9imum /aff+ requirem5ts ( clause 7ii7 (
 subsection 7b77#d77;,c7 ) respect to   
skill$ nurs+ facility s]vices provid$ on
 or aft] ,janu>y #a1 #bjbj1 ! ,/ate %all
 recomm5d to ! ,secret>y t ! ,secret>y  
take su* actions z describ$ 9 subclauses
 7,i7 & 7,,ii7 ( subp>agraph 7,b77i74   
7,b7 ,secret>ial au?ority  7i7 ,9 g5]al 
,) respect to any skill$ nurs+ facility 
9 a ,/ate1 if ! ,secret>y f9ds1 or      
pursuant to a recomm5dation ( ! ,/ate "u
 subp>agraph 7,a7 f9ds1 t a skill$ nurs+
 facility does n meet ! m9imum /aff+    
requirem5ts ( clause 7ii7 ( subsection  
7b77#d77;,c7 ) respect to skill$ nurs+  
facility s]vices provid$ on or aft]     
,janu>y #a1 #bjbj1 ! ,secret>y %all--   

7,i7 d5y any fur!r paym5ts "u ?is title 
) respect to all individuals entitl$ to 
b5efits "u ?is title :o are admitt$ to !
 facility aft] ! effective date ( !     
f9d+2 &  7,,ii7 impose a civil money    
p5alty 9 an am\nt n to exce$ #aj1jjj =  
ea* day ( noncompliance4 ,! provisions (
 section #aabh;,a 7o!r ?an subsections  
7a7 & 7b77 %all apply to a civil money  
p5alty "u ! previ\s s5t5ce 9 ! same     
mann] z su* provisions apply to a p5alty
 or proce$+ "u section #aabh;,a7a74     
7ii7 ,r$uction ( civil money p5alties 9 
c]ta9 circum/ances ,subject to clause   
7iii71 9 ! case :]e a skill$ nurs+      
facility self-reports & promptly        
corrects a defici5cy = :i* a p5alty 0   
impos$ "u clause 7i77,,ii7 n lat] ?an   
#aj cal5d> days aft] ! date ( su*       
imposition1 ! ,secret>y may r$uce !     
am\nt ( ! p5alty impos$ by--  7,i7 n m  
?an #ej p]c5t2 or  7,,ii7 9 ! case t !  
facility 0 p5aliz$ "u ?is subsection )9 
! ?ree-ye> p]iod prec$+ ! date ( su*    
imposition1 n m ?an #be p]c5t4  7iii7   

,prohibitions on r$uction = c]ta9       
defici5cies  7,i7 ,repeat defici5cies ,!
 ,secret>y may n r$uce ! am\nt ( a      
p5alty "u clause 7ii7 if ! ,secret>y _h 
r$uc$ a p5alty impos$ on ! skill$ nurs+ 
facility 9 ! prec$+ ye> "u su* clause ) 
respect to a repeat defici5cy4  7,,ii7  
,c]ta9 o!r defici5cies ,! ,secret>y may 
n r$uce ! am\nt ( a p5alty "u clause    
7ii7 if ! p5alty is impos$ on ! skill$  
nurs+ facility = a defici5cy t is f\nd  
to result 9 a patt]n ( h>m or widespread
 h>m1 imm$iately jeop>dizes ! heal? or  
safety ( a resid5t or resid5ts ( !      
facility1 or results 9 ! dea? ( a       
resid5t ( ! facility4  7iv7 ,repeat$    
noncompliance ,9 ! case ( a skill$ nurs+
 facility :i*1 on ?ree consecutive /&>d 
surveys conduct$ "u subsection 7g77#b71 
has be5 f\nd z n meet+ ! m9imum /aff+   
requirem5ts ( clause 7ii7 ( subsection  
7b77#d77;,c7 ) respect to skill$ nurs+  
facility s]vices provid$ on or aft]     
,janu>y #a1 #bjbj1 ! ,secret>y may      
7reg>dless ( ! rem$ies provid$ = "u     

clause 7i77--  7,i7 appo9t tempor>y     
managem5t to ov]see ! op]ation ( !      
facility & to assure ! heal? & safety ( 
! facility's resid5ts 9 accordance )    
clause 7iii7 ( p>agraph 7#b77;,b71      
except t ! m9imum /aff+ requirem5ts (   
clause 7ii7 ( subsection 7b77#d77;,c7   
%all be sub/itut$ = all ! requirem5ts ( 
subsections 7b71 7c71 & 7d7 "u su*      
clause2  7,,ii7 monitor ! facility "u   
subsection 7g77#d77;,b7 ) respect to su*
 m9imum /aff+ requirem5ts until !       
facility has demon/rat$ to !            
satisfaction ( ! ,secret>y t ! facility 
is 9 compliance1 & w rema9 9 compliance1
 ) su* m9imum /aff+ requirem5ts2 or     
7,,iii7 subject to section #aabh;,i7h71 
t]m9ate ! facility's p>ticipation "u ?is
 title4  ,if ! facility's p>ticipation  
"u ?is title is t]m9at$ "u ?is clause1 !
 ,/ate %all provide = ! safe & ord]ly   
transf] ( ! resid5ts eligible "u ?is    
title1 consi/5t ) ! requirem5ts (       
subsection 7c77#b7 & section            
#aabh;,i7h74  7v7 ,public notice (      

violations  7,i7 ,int]net website ,!    
,secret>y %all publi% on ! int]net      
website ( ! ,dep>tm5t ( ,heal? & ,human 
,s]vices ! names ( skill$ nurs+         
facilities t h violat$ ! m9imum /aff+   
requirem5ts ( clause 7ii7 ( subsection  
7b77#d77;,c7 ) respect to skill$ nurs+  
facility s]vices provid$ on or aft]     
,janu>y #a1 #bjbj4  7,,ii7 ,*ange (     
own]%ip ,) respect to a skill$ nurs+    
facility ^: "n is publi%$ "u subclause  
7,i7 & has a *ange ( own]%ip1 z det]m9$ 
by ! ,secret>y1 aft] ! date ( su*       
publication1 ! ,secret>y %all remove !  
"n ( su* facility f ! website describ$  
"u su* subclause aft] ! #a-ye> p]iod    
beg9n+ on ! date ( su* *ange ( own]%ip4 
4  7#c7 ,con=m+ am5dm5t ,item 7a7 (     
section #ahai7;f77#b77;,b77iii77,i7 ( ! 
,social ,security ,act 7#db ,u4,s4,c4   
#acie;i-#c7;f77#b77;,b77iii77,i77 is    
am5d$ by /rik+ subsection               
7b77#d77;,c77ii77,,ii7 & ins]t+         
subsection 7b77#d77;,c77iii77,,ii74  7b7
 ,m$icaid  7#a7 ,9 g5]al ,subp>agraph   

7,c7 ( section #aiai7;b77#d7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#acifr7b77#d77 is am5d$--  7,a7 9 clause
 7i7-- 7i7 9 ! clause head+1 by ins]t+  
aft] ,g5]al requirem5ts ! foll[+ be=e   
#bjbj2  7ii7 9 ! matt] prec$+ subclause 
7,i71 by ins]t+ aft] ,octob] #a1 #aiij1 
! foll[+3 & be=e ,janu>y #a1 #bjbj12    
7iii7 9 subclause 7,i71 by /rik+ clause 
7ii7 & ins]t+ clause 7iii72 &  7iv7 9   
subclause 7,,ii71 by /rik+ clause 7ii7 &
 ins]t+ clause 7iii72  7,b7 by          
r$esignat+ clauses 7ii7 & 7iii7 z       
clauses 7iii7 & 7iv71 respectively2 &   
7,c7 by ins]t+ aft] clause 7i7 ! foll[+ 
new clause3  7ii7 ,g5]al requirem5ts    
aft] #bjai  7,i7 ,9 g5]al ,) respect to 
nurs+ facility s]vices provid$ on or    
aft] ,janu>y #a1 #bjbj1 a nurs+ facility
 mu/--  7aa7 provide nurs+ s]vices t are
 suffici5t to meet ! nurs+ ne$s ( its   
resid5ts on a #bd-;h\r basis1 to be     
divid$ into day %ifts1 ev5+ %ifts1 &    
night %ifts2  7bb7 provide = m9imum     
nurse /aff+ levels ) respect to ea* su* 

%ift1 9 accordance ) ?is clause2 &  7cc7
 ensure t1 9 c>ry+ out items 7aa7 &     
7bb71 a total m9imum ( #d4a h\rs ( c>e  
is provid$ p] resid5t p] day1 ) #j4ge   
h\rs ( c>e ( su* total m9imum provid$ by
 a regi/]$ pr(essional nurse1 #j4ed h\rs
 ( c>e ( su* total m9imum provid$ by a  
lic5s$ practical nurse1 & #b4ha h\rs (  
c>e ( su* total m9imum provid$ by a     
nurse aide 7z def9$ 9 p>agraph          
7#e77;,f774  7,,ii7 ,day %ifts ,)       
respect to a day %ift1 ! nurs+ facility 
mu/ h-- 7aa7 at lea/ #a regi/]$         
pr(essional nurse = e #bh resid5ts1 ) a 
m9imum ( #j4bi h\rs ( c>e provid$ p]    
resid5t dur+ ea* su* %ift2  7bb7 at lea/
 #a lic5s$ practical nurse = e #dj      
resid5ts1 ) a m9imum ( #j4bj h\rs ( c>e 
provid$ p] resid5t dur+ ea* su* %ift2 & 
7cc7 at lea/ #a nurse aide 7z def9$ 9   
p>agraph 7#e77;,f77 = e #g resid5ts1 ) a
 m9imum ( #a4ad h\rs ( c>e provid$ p]   
resid5t dur+ ea* su* %ift4  7,,iii7     
,ev5+ %ifts ,) respect to an ev5+ %ift1 
! nurs+ facility mu/ h-- 7aa7 at lea/ #a

 regi/]$ pr(essional nurse = e #cj      
resid5ts1 ) a m9imum ( #j4bf h\rs ( c>e 
provid$ p] resid5t dur+ ea* su* %ift2   
7bb7 at lea/ #a lic5s$ practical nurse =
 e #dj resid5ts1 ) a m9imum ( #j4bj h\rs
 ( c>e provid$ p] resid5t dur+ ea* su*  
%ift2 &  7cc7 at lea/ #a nurse aide 7z  
def9$ 9 p>agraph 7#e77;,f77 = e #g      
resid5ts1 ) a m9imum ( #a4ad h\rs ( c>e 
provid$ p] resid5t dur+ ea* su* %ift4   
7,,iv7 ,night %ifts ,) respect to a     
night %ift1 ! nurs+ facility mu/ h--    
7aa7 at lea/ #a regi/]$ pr(essional     
nurse = e #dj resid5ts1 ) a m9imum (    
#j4bj h\rs ( c>e provid$ p] resid5t dur+
 su* %ift2  7bb7 at lea/ #a lic5s$      
practical nurse = e #ef resid5ts1 ) a   
m9imum ( #j4ad h\rs ( c>e provid$ p]    
resid5t dur+ su* %ift2 &  7cc7 at lea/  
#a nurse aide 7z def9$ 9 p>agraph       
7#e77;,f77 = e #ae resid5ts1 ) a m9imum 
( #j4ec h\rs ( c>e provid$ p] resid5t   
dur+ su* %ift4  7,v7 ,secret>ial        
au?ority to e/abli% high] m9imum nurse  
/aff+ levels ,! ,secret>y may e/abli% & 

require nurs+ facilities 7or1 at !      
,secret>y's discretion1 only nurs+      
facilities t h a high] p]c5tage (       
resid5ts ) ext5sive c>e ne$s1 z det]m9$ 
by ! ,secret>y7 to provide = m9imum     
nurse /aff+ levels t are high] ?an !    
levels requir$ "u ?is clause4  7,,vi7   
,rule ( con/ruction reg>d+ ,/ate        
au?ority to e/abli% high] m9imum nurse  
/aff+ levels ,no?+ 9 ?is clause may be  
con/ru$ z prev5t+ a ,/ate f e/abli%+ or 
requir+ nurs+ facilities 9 ! ,/ate to   
provide = m9imum nurse /aff+ levels t   
are high] ?an ! levels requir$ "u ?is   
clause4  7,,vii7 ,cl>ification ) respect
 to m9imum h\rs ( c>e provid$ p] resid5t
 requirem5ts ,9 comply+ ) ! m9imum h\rs 
( c>e provid$ p] resid5t requirem5ts "u 
?is clause1 a nurs+ facility may n c\nt 
any "t sp5t by a regi/]$ pr(essional    
nurse1 lic5s$ practical nurse1 or nurse 
aide on adm9i/rative s]vices t[>ds      
compliance ) su* requirem5ts4  7,,viii7 
,def9itions ,9 ?is clause3 7aa7         
,adm9i/rative s]vices ,! t]m            

adm9i/rative s]vices means food         
prep>ation1 h\sekeep+1 laundry s]vices1 
ma9t5ance s]vices1 & o!r                
nonc>egiv+-relat$ s]vices1 z det]m9$ by 
! ,secret>y4  7bb7 ,day %ift ,! t]m day 
%ift means1 ) respect to a day & a nurs+
 facility1 an assign$ "w %ift t is a    
p]iod ( #h consecutive h\rs1 beg9n+ n   
soon] ?an #f a4m4 9 ! "t zone 9 :i* su* 
facility is locat$ & n lat] ?an #h a4m4 
9 su* "t zone4  7cc7 ,ev5+ %ift ,! t]m  
ev5+ %ift means1 ) respect to a day & a 
nurs+ facility1 an assign$ "w %ift t is 
a p]iod ( #h consecutive h\rs1 beg9n+ n 
soon] ?an #b p4m4 9 ! "t zone 9 :i* su* 
facility is locat$ & n lat] ?an #d p4m4 
9 su* "t zone4  7dd7 ,night %ift ,! t]m 
night %ift means1 ) respect to a day & a
 nurs+ facility1 an assign$ "w %ift t is
 a p]iod ( #h consecutive h\rs1 beg9n+ n
 soon] ?an #aj p4m4 9 ! "t zone 9 :i*   
su* facility is locat$ & n lat] ?an     
midnight 9 su* "t zone4  4  7#b7        
,en=cem5t ,section #aiai7;h7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          

#acifr7h77 is am5d$-- 7,a7 9 p>agraph   
7#a71 by /rik+ ,if a ,/ate f9ds1 on !   
basis ( a /&>d & ins]t+ ,subject to     
p>agraph 7#aj71 if a ,/ate f9ds1 on !   
basis ( a /&>d2  7,b7 9 p>agraph 7#b7-- 
7i7 9 subp>agraph 7,c71 by /rik+ ,if a  
nurs+ facility & ins]t+ ,subject to     
p>agraph 7#aj71 if a nurs+ facility2 &  
7ii7 9 subp>agraph 7,d71 by /rik+ ,9 !  
case ( & ins]t+ ,subject to p>agraph    
7#aj71 9 ! case (2  7,c7 9 p>agraph     
7#c7--  7i7 9 subp>agraph 7,a71 by      
ins]t+ be=e ! p]iod ! foll[+3 & !       
rem$ies describ$ 9 p>agraph 7#aj77;,b72 
&  7ii7 9 subp>agraph 7,b71 by /rik+ ,) 
respect to & ins]t+ ,subject to p>agraph
 7#aj71 ) respect to2 &  7,d7 by add+ at
 ! end ! foll[+ new p>agraph3  7#aj7    
,special en=cem5t process ) respect to  
m9imum nurse /aff+ requirem5ts  7,a7 ,9 
g5]al ,if a ,/ate f9ds1 on ! basis ( a  
/&>d1 ext5d$1 or p>tial ext5d$ survey "u
 subsection 7g77#b7 or o!rwise1 t a     
nurs+ facility does n meet ! m9imum     
/aff+ requirem5ts ( clause 7ii7 (       

subsection 7b77#d77;,c7 ) respect to    
nurs+ facility s]vices provid$ on or    
aft] ,janu>y #a1 #bjbj1 ! ,/ate %all--  
7i7 d5y any fur!r paym5ts "u ! ,/ate    
plan ) respect to all individuals       
enroll$ "u su* plan :o are admitt$ to ! 
facility aft] ! effective date ( ! f9d+2
 &  7ii7 recomm5d to ! ,secret>y t !    
,secret>y impose ! civil money p5alty   
describ$ 9 subp>agraph 7,b74  7,b7      
,secret>ial au?ority  7i7 ,9 g5]al ,)   
respect to any nurs+ facility 9 a ,/ate 
o!r ?an a ,/ate nurs+ facility1 if !    
,secret>y f9ds t su* a nurs+ facility   
does n meet ! m9imum /aff+ requirem5ts (
 clause 7ii7 ( subsection 7b77#d77;,c7 )
 respect to nurs+ facility s]vices      
provid$ on or aft] ,janu>y #a1 #bjbj1 ! 
,secret>y %all--  7,i7 d5y any fur!r    
paym5ts to ! ,/ate = m$ical assi/ance   
furni%$ by ! facility to all individuals
 enroll$ "u ! ,/ate plan :o are admitt$ 
to ! facility aft] ! effective date ( ! 
f9d+2 &  7,,ii7 impose a civil money    
p5alty 9 an am\nt n to exce$ #aj1jjj =  

ea* day ( noncompliance4 ,! provisions (
 section #aabh;,a 7o!r ?an subsections  
7a7 & 7b77 %all apply to a civil money  
p5alty "u ! previ\s s5t5ce 9 ! same     
mann] z su* provisions apply to a p5alty
 or proce$+ "u section #aabh;,a7a74     
7ii7 ,r$uction ( civil money p5alties 9 
c]ta9 circum/ances ,subject to clause   
7iii71 9 ! case :]e a nurs+ facility    
self-reports & promptly corrects a      
defici5cy = :i* a p5alty 0 impos$ "u    
clause 7i77,,ii7 n lat] ?an #aj cal5d>  
days aft] ! date ( su* imposition1 !    
,secret>y may r$uce ! am\nt ( ! p5alty  
impos$ by--  7,i7 n m ?an #ej p]c5t2 or 
7,,ii7 9 ! case t ! facility 0 p5aliz$  
"u ?is subsection )9 ! ?ree-ye> p]iod   
prec$+ ! date ( su* imposition1 n m ?an 
#be p]c5t4  7iii7 ,prohibitions on      
r$uction = c]ta9 defici5cies  7,i7      
,repeat defici5cies ,! ,secret>y may n  
r$uce ! am\nt ( a p5alty "u clause 7ii7 
if ! ,secret>y _h r$uc$ a p5alty impos$ 
on ! nurs+ facility 9 ! prec$+ ye> "u   
su* clause ) respect to a repeat        

defici5cy4  7,,ii7 ,c]ta9 o!r           
defici5cies ,! ,secret>y may n r$uce !  
am\nt ( a p5alty "u clause 7ii7 if !    
p5alty is impos$ on ! nurs+ facility = a
 defici5cy t is f\nd to result 9 a      
patt]n ( h>m or widespread h>m1         
imm$iately jeop>dizes ! heal? or safety 
( a resid5t or resid5ts ( ! facility1 or
 results 9 ! dea? ( a resid5t ( !       
facility4  7iv7 ,repeat$ noncompliance  
,9 ! case ( a nurs+ facility :i*1 on    
?ree consecutive /&>d surveys conduct$  
"u subsection 7g77#b71 has be5 f\nd z n 
meet+ ! m9imum /aff+ requirem5ts (      
clause 7ii7 ( subsection 7b77#d77;,c7 ) 
respect to nurs+ facility s]vices       
provid$ on or aft] ,janu>y #a1 #bjbj1 ! 
,secret>y may 7reg>dless ( ! rem$ies    
provid$ = "u clause 7i77--  7,i7 appo9t 
tempor>y managem5t to ov]see ! op]ation 
( ! facility & to assure ! heal? &      
safety ( ! facility's resid5ts 9        
accordance ) clause 7iii7 ( p>agraph    
7#c77;,c71 except t ! m9imum /aff+      
requirem5ts ( clause 7ii7 ( subsection  

7b77#d77;,c7 %all be sub/itut$ = all !  
requirem5ts ( subsections 7b71 7c71 &   
7d7 "u su* clause2  7,,ii7 monitor !    
facility "u subsection 7g77#d77;,b7 )   
respect to su* m9imum /aff+ requirem5ts 
until ! facility has demon/rat$ to !    
satisfaction ( ! ,secret>y t ! facility 
is 9 compliance1 & w rema9 9 compliance1
 ) su* m9imum /aff+ requirem5ts2 or     
7,,iii7 subject to section #aabh;,i7h71 
t]m9ate ! facility's p>ticipation "u ?is
 title4  ,if ! facility's p>ticipation  
"u ?is title is t]m9at$ "u ?is clause1 !
 ,/ate %all provide = ! safe & ord]ly   
transf] ( ! resid5ts eligible "u ?is    
title1 consi/5t ) ! requirem5ts (       
subsection 7c77#b7 & section            
#aabh;,i7h74  7v7 ,public notice (      
violations  7,i7 ,int]net website ,!    
,secret>y %all publi% on ! int]net      
website ( ! ,dep>tm5t ( ,heal? & ,human 
,s]vices ! names ( nurs+ facilities t h 
violat$ ! m9imum /aff+ requirem5ts (    
clause 7ii7 ( subsection 7b77#d77;,c7 ) 
respect to skill$ nurs+ facility s]vices

 provid$ on or aft] ,janu>y #a1 #bjbj4  
7,,ii7 ,*ange ( own]%ip ,) respect to a 
nurs+ facility ^: "n is publi%$ "u      
subclause 7,i7 & has a *ange ( own]%ip1 
z det]m9$ by ! ,secret>y1 aft] ! date ( 
su* publication1 ! ,secret>y %all remove
 ! "n ( su* facility f ! website        
describ$ "u su* subclause aft] ! #a-ye> 
p]iod beg9n+ on ! date ( su* *ange (    
own]%ip4  4  7#c7 ,con=m+ am5dm5ts  7,a7
 ,clause 7iii7 ( section                
#aiai7;b77#d77;,c7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acifr7b77#d77;,c771 z r$esignat$ by    
p>agraph 7#a77;,b71 is am5d$ by /rik+   
subject to clause 7iii7 & ins]t+ subject
 to clause 7iv74  7,b7 ,item 7a7 (      
section #aiai7;f77#b77;,b77iii77,i7 ( ! 
,social ,security ,act 7#db ,u4,s4,c4   
#acifr7f77#b77;,b77iii77,i77 is am5d$ by
 /rik+ subsection 7b77#d77;,c77ii7 &    
ins]t+ subsection 7b77#d77;,c77iii74    
7,c7 ,p>agraph 7#i7 ( section #aiai7;f7 
( ! ,social ,security ,act 7#db         
,u4,s4,c4 #acifr7f77 is am5d$ by /rik+  

subsection 7b77#d77;,c77ii7 & ins]t+    
subsection 7b77#d77;,c77iii74  7c7      
,/udies & reports reg>d+ impact ( m9imum
 nurse /aff+ requirem5ts  7#a7 ,initial 
/udy & report  7,a7 ,9 g5]al ,n lat] ?an
 ,june #a1 #bjba1 ! ,secret>y ( ,heal? &
 ,human ,s]vices %all /udy & submit to !
 ,committee on ,en]gy & ,comm]ce & !    
,committee on ,ways & ,means ( ! ,h\se (
 ,repres5tatives & ! ,committee on      
,f9ance ( ! ,s5ate a publicly available 
report--  7i7 on ! impact ( ! m9imum    
nurse /aff+ requirem5ts add$ by         
subsection 7a7 on ! reimbursem5t levels 
( skill$ nurs+ facilities "u ! ,m$ic>e  
program "u title ,,xviii ( ! ,social    
,security ,act 7#db ,u4,s4,c4 #acie et  
seq47 & ! adequacy ( p]sonnel numb]s 9  
su* skill$ nurs+ facilities to meet su* 
m9imum nurse /aff+ requirem5ts2  7ii7 on
 ! impact ( ! m9imum nurse /aff+        
requirem5ts add$ by subsection 7b7 on ! 
reimbursem5t levels ( nurs+ facilities  
"u ! ,m$icaid program "u title ,,xix ( !
 ,social ,security ,act 7#db ,u4,s4,c4  

#acif et seq47 & ! adequacy ( p]sonnel  
numb]s 9 su* nurs+ facilities to meet   
su* m9imum nurse /aff+ requirem5ts2 &   
7iii7 includ+ recomm5dations on ! /eps t
 su* skill$ nurs+ facilities & nurs+    
facilities c take to ensure t adequate  
p]sonnel are available 9 su* skill$     
nurs+ facilities & nurs+ facilities to  
meet ! m9imum nurse /aff+ requirem5ts   
add$ by subsections 7a7 & 7b7 = su*     
skill$ nurs+ facilities & nurs+         
facilities1 respectively1 includ+ me?ods
 = attract+ & reta9+ su* p]sonnel4  7,b7
 ,consid]ations ,9 conduct+ ! /udy      
requir$ "u subp>agraph 7,a71 ! ,secret>y
 ( ,heal? & ,human ,s]vices %all take   
into consid]ation--  7i7 ! b5efits ( any
 increase 9 nurse /aff+ levels1 includ+ 
) respect to work=ce tra9+ & ret5tion2  
7ii7 any decrease 9 ! rate ( workplace  
injuries2  7iii7 any *anges 9 m$ical c>e
 co/s = resid5ts ( skill$ nurs+         
facilities & nurs+ facilities2  7iv7 any
 decrease 9 hospitalization rates = su* 
resid5ts2  7v7 any *anges 9 p]sonnel &  

adm9i/rative co/s = skill$ nurs+        
facilities & nurs+ facilities2 &  7vi7  
any *anges 9 recruit+ & tra9+ co/s4     
7#b7 ,subsequ5t /udy & report ,n lat]   
?an ,janu>y #a1 #bjbc1 ! ,secret>y (    
,heal? & ,human ,s]vices %all conduct a 
foll[-up /udy to ! /udy conduct$ "u     
p>agraph 7#a77;,a7 & submit to !        
,committee on ,en]gy & ,comm]ce & !     
,committee on ,ways & ,means ( ! ,h\se (
 ,repres5tatives & ! ,committee on      
,f9ance ( ! ,s5ate a publicly available 
report on su* foll[-up /udy4  #c4       
,disclosure ( nurse /aff+ levels at     
skill$ nurs+ facilities "u ,m$ic>e      
program & nurs+ facilities "u ,m$icaid  
program  7a7 ,m$ic>e ,p>agraph 7#h7 (   
section #ahai7;b7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #acie;i-#c7;b77 is  
am5d$ to read z foll[s3  7#h7 ,in=mation
 on nurse /aff+  7,a7 ,9 g5]al ,ea* day1
 a skill$ nurs+ facility %all po/ = ea* 
%ift notices )-- 7i7 a description ( !  
nurse /aff+ requirem5ts applicable )    
respect to ! facility & day "u p>agraph 

7#d77;,c72  7ii7 in=mation on ! numb] ( 
regi/]$ pr(essional nurses1 lic5s$      
practical nurses1 & nurse aides 7z def9$
 9 p>agraph 7#e77;,f77 assign$ to       
provide direct c>e s]vices to resid5ts 9
 ! facility dur+ ! %ift1 disaggregat$ by
 units 9 ! facility2 &  7iii7 a /atem5t 
t ! facility is requir$1 ^u reque/1 to  
provide any nurse /aff+ in=mation 7z    
describ$ 9 ?is subp>agraph7 ( ! facility
 f ! prec$+ #ab-mon? p]iod4  ,!         
in=mation 9 su* notices %all be writt5 9
 a uni=m mann]1 pr9t$ 9 an easily       
readable #ad-po9t type font1 & made     
available 9 appropriate languages1 z    
det]m9$ by ! ,secret>y4 ,! skill$ nurs+ 
facility %all make su* notices available
 at ea* nurses /ation 9 ! facility & o!r
 areas 9 ea* unit ( ! facility1 z       
det]m9$ appropriate by ! facility1 &    
%all keep & ma9ta9 ea* su* notice = at  
lea/ ?ree ye>s aft] ! date on :i* ea*   
su* notice is po/$ 9 ! facility4  7,b7  
,public availability ( in=mation ,a     
skill$ nurs+ facility %all1 ^u reque/1  

make available to ! public any nurse    
/aff+ in=mation 7z describ$ 9           
subp>agraph 7,a77 ( ! facility f !      
prec$+ #ab-mon? p]iod4 ,9 ! case t !    
facility makes su* in=mation available z
 a pap] copy1 su* facility may n *>ge = 
su* copy an am\nt great] ?an ! co/ (    
mak+ su* copy4  4  7b7 ,m$icaid         
,p>agraph 7#h7 ( section #aiai7;b7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#acifr7b77 is am5d$ to read z foll[s3   
7#h7 ,in=mation on nurse /aff+  7,a7 ,9 
g5]al ,ea* day1 a skill$ nurs+ facility 
%all po/ = ea* %ift notices )-- 7i7 a   
description ( ! nurse /aff+ requirem5ts 
applicable ) respect to ! facility & day
 "u p>agraph 7#d77;,c72  7ii7 in=mation 
on ! numb] ( regi/]$ pr(essional nurses1
 lic5s$ practical nurses1 & nurse aides 
7z def9$ 9 p>agraph 7#e77;,f77 assign$  
to provide direct c>e s]vices to        
resid5ts 9 ! facility dur+ ! %ift1      
disaggregat$ by units 9 ! facility2 &   
7iii7 a /atem5t t ! facility is requir$1
 ^u reque/1 to provide any nurse /aff+  

in=mation 7z describ$ 9 ?is subp>agraph7
 ( ! facility f ! prec$+ #ab-mon? p]iod4
  ,! in=mation 9 su* notices %all be    
writt5 9 a uni=m mann]1 pr9t$ 9 an      
easily readable #ad-po9t type font1 &   
made available 9 appropriate languages1 
z det]m9$ by ! ,secret>y4 ,! skill$     
nurs+ facility %all make su* notices    
available at ea* nurses /ation 9 !      
facility & o!r areas 9 ea* unit ( !     
facility1 z det]m9$ appropriate by !    
facility1 & %all keep & ma9ta9 ea* su*  
notice = at lea/ ?ree ye>s aft] ! date  
on :i* ea* su* notice is po/$ 9 !       
facility4  7,b7 ,public availability (  
in=mation ,a skill$ nurs+ facility %all1
 ^u reque/1 make available to ! public  
any nurse /aff+ in=mation 7z describ$ 9 
subp>agraph 7,a77 ( ! facility f !      
prec$+ #ab-mon? p]iod4  4  7c7          
,effective date ,! am5dm5ts made by ?is 
section take effect on ! date ( enactm5t
 ( ?is ,act & apply ) respect to nurse  
/aff+ in=mation po/$ or reque/$ on or   
aft] ! date t is "o ye> aft] su* date ( 

enactm5t4  #d4 ,adm9i/rative /aff+      
requirem5ts = skill$ nurs+ facilities "u
 ,m$ic>e program & nurs+ facilities "u  
,m$icaid program  7a7 ,m$ic>e ,p>agraph 
7#a7 ( section #ahai7;d7 ( ! ,social    
,security ,act 7#db ,u4,s4,c4           
#acie;i-#c7;d77 is am5d$-- 7#a7 by      
r$esignat+ ! second subp>agraph 7,c7 z  
subp>agraph 7,e72 &  7#b7 by ins]t+ aft]
 ! fir/ subp>agraph 7,c7 ! foll[+ new   
subp>agraph3  7,d7 ,nurs+ managem5t     
p]sonnel  7i7 ,9 g5]al ,a skill$ nurs+  
facility mu/ employ nurs+ managem5t     
p]sonnel 9 accordance ) ?is subp>agraph4
  7ii7 ,director ( nurs+ s]vices ,a     
skill$ nurs+ facility mu/ employ a      
regi/]$ pr(essional nurse to s]ve       
full-"t z ! director ( nurs+ s]vices ( !
 facility4 ,su* director ( nurs+ s]vices
 %all be responsible = det]m9+ ! numb] &
 types ( nurs+ p]sonnel ne$$ to         
suffici5tly meet ! nurs+ ne$s ( !       
resid5ts ( ! facility 7z requir$ "u     
subsection 7b77#d77;,c774  7iii7        
,assi/ant director ( nurs+ s]vices ,a   

skill$ nurs+ facility mu/ employ a      
regi/]$ pr(essional nurse to s]ve       
full-"t z ! assi/ant director ( nurs+   
s]vices ( ! facility1 except t 9 ! case 
( a skill$ nurs+ facility t has few] ?an
 #ajj b$s1 su* facility may employ a    
regi/]$ pr(essional nurse to s]ve "p-"t 
z ! assi/ant director ( nurs+ s]vices ( 
! facility4 ,a regi/]$ pr(essional nurse
 :o s]ves z ! assi/ant director ( nurs+ 
s]vices ( a skill$ nurs+ facility may   
also s]ve z a sup]visor = direct cl9ical
 nurs+ c>e = su* facility4  7iv7        
,director ( 9-,s]vice education ,a      
skill$ nurs+ facility mu/ employ a      
regi/]$ pr(essional nurse to s]ve       
full-"t z ! director ( 9-s]vice         
education ( ! facility1 except t 9 !    
case ( a skill$ nurs+ facility t has    
few] ?an #ajj b$s1 su* facility may     
employ a regi/]$ pr(essional nurse to   
s]ve "p-"t z ! director ( 9-s]vice      
education ( ! facility4 ,9 c>ry+ out !  
previ\s s5t5ce1 a skill$ nurs+ facility 
mu/1 to ! ext5t practicable &           

appropriate1 employ a regi/]$           
pr(essional nurse :o has receiv$ tra9+ 9
 adult education & g]ontology4  4  7b7  
,m$icaid  7#a7 ,9 g5]al ,p>agraph 7#a7 (
 section #aiai7;d7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acifr7d77 is am5d$
 by ins]t+ aft] subp>agraph 7,c7 !      
foll[+ new subp>agraph3  7,d7 ,nurs+    
managem5t p]sonnel  7i7 ,9 g5]al ,a     
nurs+ facility mu/ employ nurs+         
managem5t p]sonnel 9 accordance ) ?is   
subp>agraph4  7ii7 ,director ( nurs+    
s]vices ,a nurs+ facility mu/ employ a  
regi/]$ pr(essional nurse to s]ve       
full-"t z ! director ( nurs+ s]vices ( !
 facility4 ,su* director ( nurs+ s]vices
 %all be responsible = det]m9+ ! numb] &
 types ( nurs+ p]sonnel ne$$ to         
suffici5tly meet ! nurs+ ne$s ( !       
resid5ts ( ! facility 7z requir$ "u     
subsection 7b77#d77;,c774  7iii7        
,assi/ant director ( nurs+ s]vices ,a   
nurs+ facility mu/ employ a regi/]$     
pr(essional nurse to s]ve full-"t z !   
assi/ant director ( nurs+ s]vices ( !   

facility1 except t 9 ! case ( a nurs+   
facility t has few] ?an #ajj b$s1 su*   
facility may employ a regi/]$           
pr(essional nurse to s]ve "p-"t z !     
assi/ant director ( nurs+ s]vices ( !   
facility4 ,a regi/]$ pr(essional nurse  
:o s]ves z ! assi/ant director ( nurs+  
s]vices ( a nurs+ facility may also s]ve
 z a sup]visor = direct cl9ical nurs+   
c>e = su* facility4  7iv7 ,director (   
9-,s]vice education ,a nurs+ facility   
mu/ employ a regi/]$ pr(essional nurse  
to s]ve full-"t z ! director ( 9-s]vice 
education ( ! facility1 except t 9 !    
case ( a nurs+ facility t has few] ?an  
#ajj b$s1 su* facility may employ a     
regi/]$ pr(essional nurse to s]ve "p-"t 
z ! director ( 9-s]vice education ( !   
facility4 ,9 c>ry+ out ! previ\s s5t5ce1
 a nurs+ facility mu/1 to ! ext5t       
practicable & appropriate1 employ a     
regi/]$ pr(essional nurse :o has receiv$
 tra9+ 9 adult education & g]ontology4  
4  7#b7 ,te*nical am5dm5t ,p>agraph 7#a7
 ( section #aiai7;d7 ( ! ,social        

,security ,act 7#db ,u4,s4,c4 #acifr7d77
 is am5d$ by r$esignat+ subp>agraph 7,v7
 z subp>agraph 7,e74  7c7 ,effective    
date ,! am5dm5ts made by ?is section    
take effect on ! date ( enactm5t ( ?is  
,act & apply ) respect to ! adm9i/ration
 ( skill$ nurs+ facilities & nurs+      
facilities on or aft] ! date t is "o ye>
 aft] su* date ( enactm5t4  #e4 ,nurse  
tra9+ requirem5ts ) respect to skill$   
nurs+ facilities "u ,m$ic>e program &   
nurs+ facilities "u ,m$icaid program    
7a7 ,m$ic>e  7#a7 ,ori5tation = regi/]$ 
pr(essional nurses1 lic5s$ practical    
nurses1 & nurse aides ,section #ahai7;d7
 ( ! ,social ,security ,act 7#db        
,u4,s4,c4 #acie;i-#c7;d77 is am5d$ by   
add+ at ! end ! foll[+ new p>agraph3    
7#e7 ,ori5tations ,a skill$ nurs+       
facility mu/ provide to regi/]$         
pr(essional nurses1 lic5s$ practical    
nurses1 & nurse aides1 be=e su* regi/]$ 
pr(essional nurses1 lic5s$ practical    
nurses1 & nurse aides are assign$ to    
provide direct c>e s]vices to resid5ts 9

 ! facility1 ori5tations provid+        
education on ! policies & em]g5cy       
proc$ures ( ! facility & on resid5ts'   
rights "u ?is section4  4  7#b7         
,requirem5ts = nurse aide tra9+ &       
compet5cy evaluation programs & = nurse 
aide compet5cy evaluation programs      
,subp>agraph 7,a7 ( section             
#ahai7;f77#b7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acie;i-#c7;f77#b77 is  
am5d$--  7,a7 9 ! matt] prec$+ clause   
7i71 by ins]t+ aft] #aihh ! foll[+3 1 & 
update1 z det]m9$ necess>y by !         
,secret>y2  7,b7 9 clause 7i7--  7i7 by 
ins]t+ aft] c>e ( cognitively impair$   
resid5ts1 ! foll[+3 c>e ( old] adults12 
7ii7 by /rik+ pati5t abuse prev5tion    
tra9+1 & ins]t+ pati5t abuse prev5tion  
tra9+712 &  7iii7 by /rik+ #ge h\rs &   
ins]t+ #abj h\rs2 &  7,c7 9 clause      
7ii7--  7i7 by /rik+ requirem5t relat+  
to & ins]t+ requirem5ts relat+ to 7,i72 
7ii7 by ins]t+ aft] c>e ( cognitively   
impair$ resid5ts1 ! foll[+3 c>e ( old]  
adults12 &  7iii7 by /rik+ & proc$ures &

 ins]t+ 7,,ii7 m9imum h\rs ( initial &  
ongo+ tra9+ & retra9+ 7includ+ n less   
?an #abj h\rs 9 ! case ( initial tra9+71
 & 7,,iii7 proc$ures4  7b7 ,m$icaid     
7#a7 ,ori5tation = regi/]$ pr(essional  
nurses1 lic5s$ practical nurses1 & nurse
 aides ,section #aiai7;d7 ( ! ,social   
,security ,act 7#db ,u4,s4,c4 #acifr7d77
 is am5d$ by add+ at ! end ! foll[+ new 
p>agraph3  7#e7 ,ori5tations ,a nurs+   
facility mu/ provide to regi/]$         
pr(essional nurses1 lic5s$ practical    
nurses1 & nurse aides1 be=e su* regi/]$ 
pr(essional nurses1 lic5s$ practical    
nurses1 & nurse aides are assign$ to    
provide direct c>e s]vices to resid5ts 9
 ! facility1 ori5tations provid+        
education on ! policies & em]g5cy       
proc$ures ( ! facility & on resid5ts'   
rights "u ?is section4  4  7#b7         
,requirem5ts = nurse aide tra9+ &       
compet5cy evaluation programs & = nurse 
aide compet5cy evaluation programs      
,subp>agraph 7,a7 ( section             
#aiai7;f77#b7 ( ! ,social ,security ,act

 7#db ,u4,s4,c4 #acifr7f77#b77 is       
am5d$--  7,a7 9 ! matt] prec$+ clause   
7i71 by ins]t+ aft] #aihh ! foll[+3 1 & 
update1 z det]m9$ necess>y by !         
,secret>y2  7,b7 9 clause 7i7--  7i7 by 
ins]t+ aft] c>e ( cognitively impair$   
resid5ts1 ! foll[+3 c>e ( old] adults12 
7ii7 by /rik+ pati5t abuse prev5tion    
tra9+1 & ins]t+ pati5t abuse prev5tion  
tra9+712 &  7iii7 by /rik+ #ge h\rs &   
ins]t+ #abj h\rs2 &  7,c7 9 clause      
7ii7--  7i7 by /rik+ requirem5t relat+  
to & ins]t+ requirem5ts relat+ to 7,i72 
7ii7 by ins]t+ aft] c>e ( cognitively   
impair$ resid5ts1 ! foll[+3 c>e ( old]  
adults12 &  7iii7 by /rik+ & proc$ures &
 ins]t+ 7,,ii7 m9imum h\rs ( initial &  
ongo+ tra9+ & retra9+ 7includ+ n less   
?an #abj h\rs 9 ! case ( initial tra9+71
 & 7,,iii7 proc$ures4  7c7 ,effective   
date ,! am5dm5ts made by ?is section    
take effect on ! date ( enactm5t ( ?is  
,act & %all apply ) respect to nurse    
aide tra9+ & compet5cy evaluation       
programs1 nurse aide compet5cy          

evaluation programs1 & nurse ori5tations
 conduct$ on or aft] ! date t is "o ye> 
aft] su* date ( enactm5t4  #f4          
,:i/lebl[] & resid5t protections  7a7   
,m$ic>e ,section #ahai ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acie;i-#c7 is am5d$ by add+ at ! end ! 
foll[+ new subsection3  7k7 ,:i/lebl[] &
 resid5t protections  7#a7 ,/atem5t     
reg>d+ pr(essional obligation & rights  
,all nurses employ$ by a skill$ nurs+   
facility h a duty & "r to act bas$ on _!
 pr(essional judgm5t 9 accordance ) !   
nurs+ laws & regulations ( ! ,/ate 9 :i*
 su* facility is locat$1 to provide     
nurs+ c>e 9 ! exclusive int]e/s ( !     
resid5ts ( ! facility1 & to act z !     
resid5ts' advocate4  7#b7 ,objection to 
or refusal ( "w assignm5t ,a nurse may  
object to1 or refuse to p>ticipate 91   
any activity1 policy1 practice1         
assignm5t1 or task 7ref]r$ to 9 ?is     
subsection z a "w assignm5t7 if--  7,a7 
! nurse reasonably believes su* "w      
assignm5t to be 9 violation ( ! m9imum  

nurse /aff+ requirem5ts ( clause 7ii7 ( 
subsection 7b77#d77;,c72 or  7,b7 !     
nurse reasonably believes t ! nurse is n
 prep>$ by education1 tra9+1 or exp]i5ce
 to p]=m or comply ) su* "w assignm5t   
)\t compromis+ ! safety ( a resid5t or  
jeop>diz+ ! lic5se ( ! nurse4  7#c7     
,retaliation = objection to or refusal (
 "w assignm5t b>r$  7,a7 ,no dis*>ge1   
discrim9ation1 or retaliation ,no skill$
 nurs+ facility may dis*>ge1 retaliate1 
discrim9ate1 or o!rwise take adv]se     
action 9 any mann] ) respect to any     
aspect ( a nurse's employm5t ) !        
facility1 includ+ dis*>ge1 promotion1   
comp5sation1 or t]ms1 conditions1 or    
privileges ( employm5t1 bas$ on !       
nurse's objection to1 or refusal (1 a "w
 assignm5t "u p>agraph 7#b74  7,b7 ,no  
fil+ ( compla9t ,no skill$ nurs+        
facility may file a compla9t or a report
 aga9/ a nurse ) a ,/ate pr(essional    
discipl9>y ag5cy because ( ! nurse's    
objection to1 or refusal (1 a "w        
assignm5t "u p>agraph 7#b74  7#d7 ,cause

 ( action ,any nurse 7or a collective   
b>ga9+ repres5tative or legal           
repres5tative ( su* nurse7 aga9/ :om a  
skill$ nurs+ facility has tak5 an adv]se
 action 9 violation ( p>agraph          
7#c77;,a71 or aga9/ :om su* facility has
 fil$ a compla9t or report 9 violation (
 p>agraph 7#c77;,b71 may 7)\t reg>d to  
:e!r a compla9t has be5 fil$ "u p>agraph
 7#e7 or 7#aj77;,b77 br+ a cause (      
action 9 an appropriate di/rict c\rt ( !
 ,unit$ ,/ates4 ,! legal burd5s ( pro(  
specifi$ 9 section #abba7;e7 ( title #e1
 ,unit$ ,/ates ,code1 %all be controll+ 
= ! purposes ( any cause ( action br\ght
 "u ?is p>agraph4 ,a nurse :o prevails  
on ! cause ( action may be entitl$ to "o
 or m ( ! foll[+3  7,a7 ,re9/atem5t4    
7,b7 ,reimbursem5t ( lo/ wages1         
comp5sation1 & b5efits4  7,c7           
,attorneys' fees4  7,d7 ,c\rt co/s4     
7,e7 ,o!r damages4  7#e7 ,compla9t to   
,secret>y ,any individual may file a    
compla9t ) ! ,secret>y aga9/ a skill$   
nurs+ facility t violates a requirem5t  

describ$ 9 p>agraph 7#c74 ,= any        
compla9t fil$1 ! ,secret>y %all--  7,a7 
receive & inve/igate ! compla9t2  7,b7  
det]m9e :e!r a violation ( su* p>agraph1
 z alleg$ 9 ! compla9t1 has occurr$2 &  
7,c7 9 ! case t ! ,secret>y det]m9es t  
su* a violation has occurr$1 issue an   
ord] t ! compla9+ individual may n suff]
 any adv]se action prohibit$ by p>agraph
 7#c7 or 7#g74  7#f7 ,toll-,free        
telephone numb]  7,a7 ,9 g5]al ,!       
,secret>y %all provide = ! e/abli%m5t ( 
a toll-free telephone hotl9e to provide 
in=mation reg>d+ ! m9imum nurse /aff+   
requirem5ts ( clause 7ii7 ( subsection  
7b77#d77;,c7 & to receive reports (     
violations ( su* requirem5ts4  7,b7     
,notice to resid5ts ,a skill$ nurs+     
facility %all provide ea* resid5t       
admitt$ to ! facility ) ! telephone     
numb] ( ! hotl9e describ$ 9 subp>agraph 
7,a7 & give notice to ea* su* resid5t t 
su* hotl9e may be us$ to report         
inadequate /aff+4  7#g7 ,protection =   
report+  7,a7 ,prohibition on           

retaliation or discrim9ation ,a skill$  
nurs+ facility may n retaliate or       
discrim9ate 9 any mann] aga9/ any       
resid5t1 employee1 or contract employee 
( ! facility1 or any o!r individual1 on 
! basis t su* resid5t1 employee1        
contract employee1 or individual        
7individually or 9 conjunction ) ano!r  
individual7 has1 9 good fai?--  7i7     
pres5t$ a grievance or compla9t2  7ii7  
initiat$ or coop]at$ 9 any inve/igation 
or proce$+ ( any gov]nm5tal entity1     
regulatory ag5cy1 or private            
accr$itation body2  7iii7 made a civil  
claim or dem&2 or  7iv7 fil$ an action  
relat+ to ! c>e1 s]vices1 or conditions 
( ! facility4  7,b7 ,good fai? def9$ ,= 
purposes ( ?is p>agraph1 an individual  
%all be deem$ to be act+ 9 good fai? if 
! individual reasonably believes--  7i7 
! in=mation report$ or disclos$ is true2
 &  7ii7 a violation ( ! m9imum nurse   
/aff+ requirem5ts ( clause 7ii7 (       
subsection 7b77#d77;,c7 has occurr$ or  
may occur4  7#h7 ,prohibition on        

int]f]5ce ) rights  7,a7 ,ex]cise (     
rights ,a skill$ nurs+ facility may n-- 
7i7 int]f]e )1 re/ra91 or d5y ! ex]cise1
 or attempt to ex]cise1 by any          
individual ( any "r1 proc$ure1 or rem$y 
provid$ or protect$ "u ?is subsection2  
or  7ii7 co]ce or intimidate any        
individual reg>d+ ! ex]cise1 or attempt 
to ex]cise1 su* "r4  7,b7 ,opposition to
 unlawful policies or practices ,a      
skill$ nurs+ facility may n retaliate or
 discrim9ate aga9/ any individual =     
oppos+ any policy1 practice1 or action (
 ! facility :i* is alleg$ to violate1   
brea*1 or fail to comply ) any provision
 ( ! m9imum nurse /aff+ requirem5ts (   
clause 7ii7 ( subsection 7b77#d77;,c74  
7,c7 ,prohibition on int]f]5ce )        
protect$ communications ,a skill$ nurs+ 
facility may n make1 adopt1 or en=ce any
 rule1 regulation1 policy1 or practice  
:i* 9 any mann] directly or indirectly  
prohibits1 imp$es1 or disc\rages a nurse
 f1 or intimidates1 co]ces1 or induces a
 nurse reg>d+1 engag+ 9 free spee*      

activities or disclos+ in=mation z      
provid$ "u ?is subsection4  7,d7        
,prohibition on int]f]5ce ) collective  
action ,a skill$ nurs+ facility may n 9 
any way int]f]e ) ! rights ( nurses to  
organize1 b>ga9 collectively1 & engage 9
 conc]t$ activity "u section #g ( !     
,national ,labor ,relations ,act 7#bi   
,u4,s4,c4 #aeg74  7#i7 ,notice ,a skill$
 nurs+ facility %all po/ 9 an           
appropriate location 9 ea* unit a       
conspicu\s notice1 9 a =m specifi$ by ! 
,secret>y1 t--  7,a7 expla9s ! rights ( 
nurses1 resid5ts1 & o!r individuals "u  
?is subsection2  7,b7 includes a /atem5t
 t a nurse1 resid5t1 or o!r individual  
may file a compla9t ) ! ,secret>y aga9/ 
! facility = a violation ( a requirem5t 
or a prohibition ( ?is subsection2 &    
7,c7 provides in/ructions on h[ to file 
su* a compla9t4  7#aj7 ,en=cem5t  7,a7  
,9 g5]al ,! ,secret>y %all en=ce !      
requirem5ts & prohibitions ( ?is        
subsection 9 accordance ) ?is p>agraph4 
7,b7 ,proc$ures = receiv+ & inve/igat+  

compla9ts ,! ,secret>y %all e/abli%     
proc$ures "u :i*-- 7i7 any individual   
may file a compla9t alleg+ t a skill$   
nurs+ facility has violat$ a requirem5t 
or a prohibition ( ?is subsection2 &    
7ii7 any su* compla9t %all be inve/igat$
 by ! ,secret>y4  7,c7 ,rem$ies ,if !   
,secret>y det]m9es t a skill$ nurs+     
facility has violat$ a requirem5t or    
prohibition ( ?is subsection1 !         
,secret>y--  7i7 %all require ! facility
 to e/abli% a corrective action plan to 
prev5t ! recurr5ce ( su* violation2 &   
7ii7 may impose civil money p5alties z  
describ$ 9 subp>agraph 7,d74  7,d7      
,civil p5alties  7i7 ,9 g5]al ,9        
addition to any o!r p5alties prescrib$  
by law1 ! ,secret>y may impose civil    
p5alties z foll[s3  7,i7 ,skill$ nurs+  
facility liability ,! ,secret>y may     
impose on a skill$ nurs+ facility f\nd  
to be 9 violation ( ?is subsection a    
civil money p5alty (--  7aa7 n m ?an    
#be1jjj = ! fir/ kn[+ violation ( ?is   
subsection by su* facility2 &  7bb7 n m 

?an #ej1jjj = any subsequ5t kn[+        
violation ( ?is subsection by su*       
facility4  7,,ii7 ,individual liability 
,! ,secret>y may impose on an individual
 :o-- 7aa7 is employ$ by a skill$ nurs+ 
facility2 &  7bb7 is f\nd by ! ,secret>y
 to h kn[+ly violat$ ?is subsection on  
behalf ( ! facility1  a civil money     
p5alty ( n m ?an #bj1jjj = ea* su*      
violation by ! individual4  7ii7        
,proc$ures ,! provisions ( section      
#aabh;,a ( ! ,social ,security ,act 7o!r
 ?an subsections 7a7 & 7b77 %all apply )
 respect to a civil money p5alty or     
proce$+ "u ?is subp>agraph 9 ! same     
mann] z su* provisions apply ) respect  
to a civil money p5alty or proce$+ "u   
su* section #aabh;,a4  7,e7 ,public     
notice ( violations  7i7 ,int]net       
website ,! ,secret>y %all publi% on !   
int]net website ( ! ,dep>tm5t ( ,heal? &
 ,human ,s]vices ! names ( skill$ nurs+ 
facilities on :i* a civil money p5alty  
has be5 impos$ "u ?is subsection1 !     
violation = :i* su* p5alty 0 impos$1 &  

su* additional in=mation z ! ,secret>y  
det]m9es appropriate4  7ii7 ,*ange (    
own]%ip ,) respect to a skill$ nurs+    
facility t _h a *ange ( own]%ip1 z      
det]m9$ by ! ,secret>y1 p5alties impos$ 
on ! facility :ile "u previ\s own]%ip   
%all no long] be publi%$ by ! ,secret>y 
pursuant to clause 7i7 aft] ! #a-ye>    
p]iod beg9n+ on ! date ( su* *ange (    
own]%ip4  7,f7 ,use ( funds ,funds      
collect$ by ! ,secret>y pursuant to ?is 
subsection are au?oriz$ to be           
appropriat$ to implem5t ! m9imum nurse  
/aff+ requirem5ts ( clause 7ii7 (       
subsection 7b77#d77;,c74  7#aa7 ,nurse  
def9$ ,9 ?is subsection1 ! t]m nurse    
means a regi/]$ pr(essional nurse1 a    
lic5s$ practical nurse1 & a nurse aide4 
4  7b7 ,m$icaid ,section #aiai ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#acifr7 is am5d$ by add+ at ! end !     
foll[+ new subsection3  7k7 ,:i/lebl[] &
 resid5t protections  7#a7 ,/atem5t     
reg>d+ pr(essional obligation & rights  
,all nurses employ$ by a nurs+ facility 

h a duty & "r to act bas$ on _!         
pr(essional judgm5t 9 accordance ) !    
nurs+ laws & regulations ( ! ,/ate 9 :i*
 su* facility is locat$1 to provide     
nurs+ c>e 9 ! exclusive int]e/s ( !     
resid5ts ( ! facility1 & to act z !     
resid5ts' advocate4  7#b7 ,objection to 
or refusal ( "w assignm5t ,a nurse may  
object to1 or refuse to p>ticipate 91   
any activity1 policy1 practice1         
assignm5t1 or task 7ref]r$ to 9 ?is     
subsection z a "w assignm5t7 if--  7,a7 
! nurse reasonably believes su* "w      
assignm5t to be 9 violation ( ! m9imum  
nurse /aff+ requirem5ts ( clause 7ii7 ( 
subsection 7b77#d77;,c72 or  7,b7 !     
nurse reasonably believes t ! nurse is n
 prep>$ by education1 tra9+1 or exp]i5ce
 to p]=m or comply ) su* "w assignm5t   
)\t compromis+ ! safety ( a resid5t or  
jeop>diz+ ! lic5se ( ! nurse4  7#c7     
,retaliation = objection to or refusal (
 "w assignm5t b>r$  7,a7 ,no dis*>ge1   
discrim9ation1 or retaliation ,no nurs+ 
facility may dis*>ge1 retaliate1        

discrim9ate1 or o!rwise take adv]se     
action 9 any mann] ) respect to any     
aspect ( a nurse's employm5t ) !        
facility1 includ+ dis*>ge1 promotion1   
comp5sation1 or t]ms1 conditions1 or    
privileges ( employm5t1 bas$ on !       
nurse's objection to1 or refusal (1 a "w
 assignm5t "u p>agraph 7#b74  7,b7 ,no  
fil+ ( compla9t ,no nurs+ facility may  
file a compla9t or a report aga9/ a     
nurse ) a ,/ate pr(essional discipl9>y  
ag5cy because ( ! nurse's objection to1 
or refusal (1 a "w assignm5t "u p>agraph
 7#b74  7#d7 ,cause ( action ,any nurse 
7or a collective b>ga9+ repres5tative or
 legal repres5tative ( su* nurse7 aga9/ 
:om a nurs+ facility has tak5 an adv]se 
action 9 violation ( p>agraph 7#c77;,a71
 or aga9/ :om su* facility has fil$ a   
compla9t or report 9 violation (        
p>agraph 7#c77;,b71 may 7)\t reg>d to   
:e!r a compla9t has be5 fil$ "u p>agraph
 7#e7 or 7#aj77;,b77 br+ a cause (      
action 9 an appropriate di/rict c\rt ( !
 ,unit$ ,/ates4 ,! legal burd5s ( pro(  

specifi$ 9 section #abba7;e7 ( title #e1
 ,unit$ ,/ates ,code1 %all be controll+ 
= ! purposes ( any cause ( action br\ght
 "u ?is p>agraph4 ,a nurse :o prevails  
on ! cause ( action may be entitl$ to "o
 or m ( ! foll[+3  7,a7 ,re9/atem5t4    
7,b7 ,reimbursem5t ( lo/ wages1         
comp5sation1 & b5efits4  7,c7           
,attorneys' fees4  7,d7 ,c\rt co/s4     
7,e7 ,o!r damages4  7#e7 ,compla9t to   
,secret>y ,any individual may file a    
compla9t ) ! ,secret>y aga9/ a nurs+    
facility t violates a requirem5t        
describ$ 9 p>agraph 7#c74 ,= any        
compla9t fil$1 ! ,secret>y %all--  7,a7 
receive & inve/igate ! compla9t2  7,b7  
det]m9e :e!r a violation ( su* p>agraph1
 z alleg$ 9 ! compla9t1 has occurr$2 &  
7,c7 9 ! case t ! ,secret>y det]m9es t  
su* a violation has occurr$1 issue an   
ord] t ! compla9+ individual may n suff]
 any adv]se action prohibit$ by p>agraph
 7#c7 or 7#g74  7#f7 ,toll-,free        
telephone numb]  7,a7 ,9 g5]al ,!       
,secret>y %all provide = ! e/abli%m5t ( 

a toll-free telephone hotl9e to provide 
in=mation reg>d+ ! m9imum nurse /aff+   
requirem5ts ( clause 7ii7 ( subsection  
7b77#d77;,c7 & to receive reports (     
violations ( su* requirem5ts4  7,b7     
,notice to resid5ts ,a nurs+ facility   
%all provide ea* resid5t admitt$ to !   
facility ) ! telephone numb] ( ! hotl9e 
describ$ 9 subp>agraph 7,a7 & give      
notice to ea* su* resid5t t su* hotl9e  
may be us$ to report inadequate /aff+ or
 c>e4  7#g7 ,protection = report+  7,a7 
,prohibition on retaliation or          
discrim9ation ,a nurs+ facility may n   
retaliate or discrim9ate 9 any mann]    
aga9/ any resid5t1 employee1 or contract
 employee ( ! facility1 or any o!r      
individual1 on ! basis t su* resid5t1   
employee1 contract employee1 or         
individual 7individually or 9           
conjunction ) ano!r individual7 has1 9  
good fai?--  7i7 pres5t$ a grievance or 
compla9t2  7ii7 initiat$ or coop]at$ 9  
any inve/igation or proce$+ ( any       
gov]nm5tal entity1 regulatory ag5cy1 or 

private accr$itation body2  7iii7 made a
 civil claim or dem&2 or  7iv7 fil$ an  
action relat+ to ! c>e1 s]vices1 or     
conditions ( ! facility4  7,b7 ,good    
fai? def9$ ,= purposes ( ?is p>agraph1  
an individual %all be deem$ to be act+ 9
 good fai? if ! individual reasonably   
believes--  7i7 ! in=mation report$ or  
disclos$ is true2 &  7ii7 a violation ( 
! m9imum nurse /aff+ requirem5ts (      
clause 7ii7 ( subsection 7b77#d77;,c7   
has occurr$ or may occur4  7#h7         
,prohibition on int]f]5ce ) rights  7,a7
 ,ex]cise ( rights ,a nurs+ facility may
 n-- 7i7 int]f]e )1 re/ra91 or d5y !    
ex]cise1 or attempt to ex]cise1 by any  
individual ( any "r1 proc$ure1 or rem$y 
provid$ or protect$ "u ?is subsection2  
or  7ii7 co]ce or intimidate any        
individual reg>d+ ! ex]cise1 or attempt 
to ex]cise1 su* "r4  7,b7 ,opposition to
 unlawful policies or practices ,a nurs+
 facility may n retaliate or discrim9ate
 aga9/ any individual = oppos+ any      
policy1 practice1 or action ( ! facility

 :i* is alleg$ to violate1 brea*1 or    
fail to comply ) any provision ( !      
m9imum nurse /aff+ requirem5ts ( clause 
7ii7 ( subsection 7b77#d77;,c74  7,c7   
,prohibition on int]f]5ce ) protect$    
communications ,a nurs+ facility may n  
make1 adopt1 or en=ce any rule1         
regulation1 policy1 or practice :i* 9   
any mann] directly or indirectly        
prohibits1 imp$es1 or disc\rages a nurse
 f1 or intimidates1 co]ces1 or induces a
 nurse reg>d+1 engag+ 9 free spee*      
activities or disclos+ in=mation z      
provid$ "u ?is subsection4  7,d7        
,prohibition on int]f]5ce ) collective  
action ,a nurs+ facility may n 9 any way
 int]f]e ) ! rights ( nurses to         
organize1 b>ga9 collectively1 & engage 9
 conc]t$ activity "u section #g ( !     
,national ,labor ,relations ,act 7#bi   
,u4,s4,c4 #aeg74  7#i7 ,notice ,a nurs+ 
facility %all po/ 9 an appropriate      
location 9 ea* unit a conspicu\s notice1
 9 a =m specifi$ by ! ,secret>y1 t--    
7,a7 expla9s ! rights ( nurses1         

resid5ts1 & o!r individuals "u ?is      
subsection2  7,b7 includes a /atem5t t a
 nurse1 resid5t1 or o!r individual may  
file a compla9t ) ! ,secret>y aga9/ !   
facility = a violation ( a requirem5t or
 a prohibition ( ?is subsection2 &  7,c7
 provides in/ructions on h[ to file su* 
a compla9t4  7#aj7 ,en=cem5t  7,a7 ,9   
g5]al ,! ,secret>y %all en=ce !         
requirem5ts & prohibitions ( ?is        
subsection 9 accordance ) ?is p>agraph4 
7,b7 ,proc$ures = receiv+ & inve/igat+  
compla9ts ,! ,secret>y %all e/abli%     
proc$ures "u :i*-- 7i7 any individual   
may file a compla9t alleg+ t a nurs+    
facility has violat$ a requirem5t or a  
prohibition ( ?is subsection2 &  7ii7   
any su* compla9t %all be inve/igat$ by !
 ,secret>y4  7,c7 ,rem$ies ,if !        
,secret>y det]m9es t a nurs+ facility   
has violat$ a requirem5t or prohibition 
( ?is subsection1 ! ,secret>y--  7i7    
%all require ! facility to e/abli% a    
corrective action plan to prev5t !      
recurr5ce ( su* violation2 &  7ii7 may  

impose civil money p5alties z describ$ 9
 subp>agraph 7,d74  7,d7 ,civil p5alties
  7i7 ,9 g5]al ,9 addition to any o!r   
p5alties prescrib$ by law1 ! ,secret>y  
may impose civil p5alties z foll[s3     
7,i7 ,nurs+ facility liability ,!       
,secret>y may impose on a nurs+ facility
 f\nd to be 9 violation ( ?is subsection
 a civil money p5alty (--  7aa7 n m ?an 
#be1jjj = ! fir/ kn[+ violation ( ?is   
subsection by su* facility2 &  7bb7 n m 
?an #ej1jjj = any subsequ5t kn[+        
violation ( ?is subsection by su*       
facility4  7,,ii7 ,individual liability 
,! ,secret>y may impose on an individual
 :o-- 7aa7 is employ$ by a nurs+        
facility2 &  7bb7 is f\nd by ! ,secret>y
 to h kn[+ly violat$ ?is subsection on  
behalf ( ! facility1  a civil money     
p5alty ( n m ?an #bj1jjj = ea* su*      
violation by ! individual4  7ii7        
,proc$ures ,! provisions ( section      
#aabh;,a ( ! ,social ,security ,act 7o!r
 ?an subsections 7a7 & 7b77 %all apply )
 respect to a civil money p5alty or     

proce$+ "u ?is subp>agraph 9 ! same     
mann] z su* provisions apply ) respect  
to a civil money p5alty or proce$+ "u   
su* section #aabh;,a4  7,e7 ,public     
notice ( violations  7i7 ,int]net       
website ,! ,secret>y %all publi% on !   
int]net website ( ! ,dep>tm5t ( ,heal? &
 ,human ,s]vices ! names ( nurs+        
facilities on :i* a civil money p5alty  
has be5 impos$ "u ?is subsection1 !     
violation = :i* su* p5alty 0 impos$1 &  
su* additional in=mation z ! ,secret>y  
det]m9es appropriate4  7ii7 ,*ange (    
own]%ip ,) respect to a nurs+ facility t
 _h a *ange ( own]%ip1 z det]m9$ by !   
,secret>y1 p5alties impos$ on ! facility
 :ile "u previ\s own]%ip %all no long]  
be publi%$ by ! ,secret>y pursuant to   
clause 7i7 aft] ! #a-ye> p]iod beg9n+ on
 ! date ( su* *ange ( own]%ip4  7,f7    
,use ( funds ,funds collect$ by !       
,secret>y pursuant to ?is subsection are
 au?oriz$ to be appropriat$ to implem5t 
! m9imum nurse /aff+ requirem5ts (      
clause 7ii7 ( subsection 7b77#d77;,c74  

7#aa7 ,nurse def9$ ,9 ?is subsection1 ! 
t]m nurse means a regi/]$ pr(essional   
nurse1 a lic5s$ practical nurse1 & a    
nurse aide4  4  7c7 ,effective date ,!  
am5dm5ts made by ?is section take effect
 on ! date ( enactm5t ( ?is ,act & %all 
apply ) respect to objections to or     
refusals ( "w assignm5ts1 compla9ts1    
retaliations & o!r adv]se actions1 &    
int]f]5ces ) rights t occur on or aft] !
 date t is "o ye> aft] su* date (       
enactm5t & ) respect to notices provid$ 
on or aft] ! date t is "o ye> aft] su*  
date ( enactm5t4  #g4 ,prohibit+        
pre-dispute arbitration agreem5ts  7a7  
,m$ic>e ,section #ahai7;c7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4           
#acie;i-#c7;c77 is am5d$ by add+ at !   
end ! foll[+ new p>agraph3  7#g7        
,prohibition on use ( pre-dispute       
arbitration agreem5ts  7,a7 ,9 g5]al ,a 
skill$ nurs+ facility may n require1    
solicit1 accept1 or move to en=ce a     
pre-dispute arbitration agreem5t f or on
 behalf ( any resid5t1 :e!r ! agreem5t  

is made be=e1 dur+1 or aft] ! resid5t's 
admission to ! facility1 or f or on     
behalf ( any employee1 or contract      
employee ( ! facility1 or any o!r       
individual if su* individual is alleg$  
to be engag$ 9 conduct protect$ "u      
subsection 7k74  7,b7 ,application ,?is 
p>agraph %all apply to ! skill$ nurs+   
facility & to any o!r bus9ess or p]son  
provid+ or responsible = provid+ skill$ 
nurs+ s]vices to ! resid5t4  7,c7 ,no   
validity or en=cem5t ,a pre-dispute     
arbitration agreem5t %all n be valid or 
specifically en=ceable aga9/ a resid5t  
or =m] resid5t ( a skill$ nurs+         
facility1 )\t reg>d to :e!r ! agreem5t 0
 made prior to or aft] ! effective date 
( ?is p>agraph4  7,d7 ,def9ition (      
pre-dispute arbitration agreem5t ,9 ?is 
p>agraph1 ! t]m pre-dispute arbitration 
agreem5t means any agreem5t to arbitrate
 a dispute :5 ! dispute has aris5 aft]  
su* agreem5t has be5 made4  7,e7        
,judicial review ,a det]m9ation z to    
:e!r & h[ ?is p>agraph applies to an    

arbitration agreem5t %all be det]m9$ "u 
,f$]al law by a c\rt ( compet5t         
jurisdiction1 r ?an an arbitrator1 )\t  
reg>d to :e!r ! p>ty oppos+ arbitration 
*all5ges su* agreem5t specifically or 9 
conjunction ) any o!r t]m ( ! contract  
conta9+ su* agreem5t4  4  7b7 ,m$icaid  
7#a7 ,home & community-bas$ s]vices &   
home heal? c>e s]vices ,section #aiae ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#acifn7 is am5d$ by add+ at ! end !     
foll[+ new subsection3  7l7 ,prohibit+  
pre-,dispute arbitration agreem5ts  7#a7
 ,9 g5]al ,= home & community-bas$      
s]vices or home heal? c>e s]vices       
provid$ "u a waiv] "u ?is section1      
section #aijb7;a77#aj77;,d71 or any o!r 
provision au?oriz+ ! provision ( home & 
community-bas$ s]vices or home heal? c>e
 s]vices "u ?is title1 ! provid] ( su*  
s]vices 7& any employee1 ag5t1 relat$   
entity1 or affiliate ( su* provid]7 %all
 n require1 solicit1 or accept a        
pre-dispute arbitration agreem5t f or on
 behalf ( any individual receiv+ su*    

s]vices1 :e!r ! agreem5t is made be=e1  
dur+1 or aft] ! fir/ date on :i* s]vices
 are receiv$1 or f or on behalf ( any   
employee1 or contract employee ( !      
provid]1 or any o!r individual if su*   
individual is alleg$ to be engag$ 9     
conduct protect$ "u section #aiai7k74 ,a
 pre-dispute arbitration agreem5t betwe5
 su* a provid] 7or entity or p]son7 & an
 individual receiv+ s]vices 7or :o =m]ly
 receiv$ s]vices7 %all n be valid or    
en=ceable1 )\t reg>d to :e!r su*        
agreem5t 0 made prior to ! effective    
date ( ?is subsection4  7#b7 ,def9ition 
( pre-dispute arbitration agreem5t ,!   
t]m pre-dispute arbitration agreem5t    
means any agreem5t to arbitrate a       
dispute :5 ! dispute has aris5 aft] su* 
agreem5t has be5 made4  7#c7 ,judicial  
review ,a det]m9ation z to :e!r & h[ ?is
 subsection applies to an arbitration   
agreem5t %all be det]m9$ "u ,f$]al law  
by a c\rt ( compet5t jurisdiction1 r ?an
 an arbitrator1 )\t reg>d to :e!r ! p>ty
 oppos+ arbitration *all5ges su*        

agreem5t specifically or 9 conjunction )
 any o!r t]m ( ! contract conta9+ su*   
agreem5t4  4  7#b7 ,nurs+ facilities    
,section #aiai7;c7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acifr7c77 is am5d$
 by add+ at ! end ! foll[+ new p>agraph3
  7#i7 ,prohibition on use ( pre-dispute
 arbitration agreem5ts  7,a7 ,9 g5]al ,a
 nurs+ facility may n require1 solicit1 
accept1 or move to en=ce a pre-dispute  
arbitration agreem5t f or on behalf (   
any resid5t1 :e!r ! agreem5t is made    
be=e1 dur+1 or aft] ! resid5t's         
admission to ! facility1 or f or on     
behalf ( any employee1 or contract      
employee ( ! facility1 or any o!r       
individual if su* individual is alleg$  
to be engag$ 9 conduct protect$ "u      
subsection 7k74  7,b7 ,application ,?is 
p>agraph %all apply to ! nurs+ facility 
& to any o!r bus9ess or p]son provid+ or
 responsible = provid+ nurs+ s]vices to 
! resid5t4  7,c7 ,no validity or        
en=cem5t ,a pre-dispute arbitration     
agreem5t %all n be valid or specifically

 en=ceable aga9/ a resid5t or =m]       
resid5t ( a nurs+ facility1 )\t reg>d to
 :e!r ! agreem5t 0 made prior to or aft]
 ! effective date ( ?is p>agraph4  7,d7 
,def9ition ( pre-dispute arbitration    
agreem5t ,9 ?is p>agraph1 ! t]m         
pre-dispute arbitration agreem5t means  
any agreem5t to arbitrate a dispute :5 !
 dispute has aris5 aft] su* agreem5t has
 be5 made4  7,e7 ,judicial review ,a    
det]m9ation z to :e!r & h[ ?is p>agraph 
applies to an arbitration agreem5t %all 
be det]m9$ "u ,f$]al law by a c\rt (    
compet5t jurisdiction1 r ?an an         
arbitrator1 )\t reg>d to :e!r ! p>ty    
oppos+ arbitration *all5ges su* agreem5t
 specifically or 9 conjunction ) any o!r
 t]m ( ! contract conta9+ su* agreem5t4 
4  #h4 ,/&>diz$ protocol = obta9+ in=m$ 
cons5t f resid5ts prior to prescrib+    
psy*otropic drugs  7a7 ,/&>diz$ protocol
  7#a7 ,skill$ nurs+ facilities ,section
 #ahai7;b7 ( ! ,social ,security ,act   
7#db ,u4,s4,c4 #acie;i-#c7;b77 is am5d$ 
by add+ at ! end ! foll[+ new p>agraph3 

7#i7 ,/&>diz$ protocol = obta9+ in=m$   
cons5t f a resid5t prior to prescrib+   
psy*otropic drugs = a use n approv$ by !
 ,food & ,drug ,adm9i/ration  7,a7      
,protocol ,n lat] ?an ! date t is "o ye>
 aft] ! date ( ! enactm5t ( ?is         
p>agraph1 ! ,secret>y1 tak+ into acc\nt 
! results ( ! /udy conduct$ by !        
,comptroll] ,g5]al ( ! ,unit$ ,/ates "u 
section #h7;a77#c7 ( ! ,quality ,c>e =  
,nurs+ ,home ,resid5ts ,act ( #bjai & 9 
consultation ) /akehold] gr\ps 7includ+ 
resid5ts ( skill$ nurs+ facilities1     
family memb]s ( su* resid5ts1 advocates 
= su* resid5ts1 long-t]m c>e ombudsm51 &
 provid]s71 %all develop a /&>diz$      
protocol = skill$ nurs+ facilities to   
obta9 writt5 in=m$ cons5t1 9 accordance 
) ?is p>agraph1 f a resid5t 7or1 if     
applicable1 ! resid5t's designat$ heal? 
c>e ag5t or o!r surrogate "u ,/ate law  
or regulation7 prior to prescrib+ a     
psy*otropic drug to ! resid5t = a use n 
approv$ by ! ,food & ,drug              
,adm9i/ration4  7,b7 ,requirem5ts ,!    

/&>diz$ protocol develop$ "u subp>agraph
 7,a7 %all include ! foll[+3 7i7 ,a     
requirem5t1 ) respect to a resid5t1 t-- 
7,i7 ! facility1 ) ! involvem5t ( !     
prescrib]1 in=m ! resid5t 7or1 if       
applicable1 ! resid5t's designat$ heal? 
c>e ag5t or o!r surrogate "u ,/ate law  
or regulation7 (--  7aa7 possible side  
effects & risks associat$ ) !           
psy*otropic drug1 includ+ ! m5tion ( any
 black box w>n+2  7bb7 treatm5t         
modalities t 7 attempt$ prior to ! use (
 ! psy*otropic drug2 &  7cc7 any o!r    
in=mation ! ,secret>y det]m9es          
appropriate2  7,,ii7 ! resid5t 7or1 if  
applicable1 ! resid5t's designat$ heal? 
c>e ag5t or o!r surrogate "u ,/ate law  
or regulation7 provide writt5 in=m$     
cons5t to ! adm9i/ration ( ! psy*otropic
 drug2 &  7,,iii7 ! adm9i/ration ( !    
psy*otropic drug is 9 accordance ) any  
plan ( c>e t ! resid5t has 9 place1     
includ+ non-ph>macological int]v5tions z
 appropriate t c effectively address    
und]ly+ m$ical & environm5tal causes (  

behavioral disord]s4  7ii7 ,an          
alt]native protocol = obta9+ su* writt5 
in=m$ cons5t-- 7,i7 9 ! case (          
em]g5cies2 &  7,,ii7 9 ! abs5ce ( a     
cle>ly id5tifi$ designat$ heal? c>e ag5t
 or o!r surrogate "u ,/ate law or       
regulation4  7iii7 ,o!r items det]m9$   
appropriate by ! ,secret>y4  7,c7 ,tim+ 
( in=m$ cons5t ,"u ! /&>diz$ protocol1 a
 skill$ nurs+ facility %all obta9 !     
writt5 in=m$ cons5t describ$ 9          
subp>agraph 7,a71 ) respect to a        
psy*otropic drug & a resid5t ( !        
facility--  7i7 prior to ! initial      
prescrib+ ( su* psy*otropic drug to su* 
resid5t if su* resid5t does n h a curr5t
 prescription = su* psy*otropic drug at 
! "t su* resid5t is admitt$ to !        
facility2 &  7ii7 at lea/ once a mon? to
 ! ext5t t ! adm9i/ration ( su*         
psy*otropic drug to su* resid5t is 9    
accordance ) ! plan ( c>e t ! resid5t   
has 9 place4  7,d7 ,compliance          
,effective beg9n+ on ! date t is "o ye> 
& #ahj days aft] ! date ( ! enactm5t (  

?is p>agraph1 a skill$ nurs+ facility   
%all comply ) ! /&>diz$ protocol        
develop$ "u subp>agraph 7,a74  7,e7 ,no 
preemption ,no?+ 9 ?is p>agraph %all    
preempt any provision ( ,/ate or ,f$]al 
law t provides broad] rights ) respect  
to writt5 in=m$ cons5t = resid5ts (     
facilities4  4  7#b7 ,nurs+ facilities  
,section #aiai7;b7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acifr7b77 is am5d$
 by add+ at ! end ! foll[+ new p>agraph3
  7#i7 ,/&>diz$ protocol = obta9+ in=m$ 
cons5t f a resid5t prior to prescrib+   
psy*otropic drugs = a use n approv$ by !
 ,food & ,drug ,adm9i/ration  7,a7      
,protocol ,n lat] ?an ! date t is "o ye>
 aft] ! date ( ! enactm5t ( ?is         
p>agraph1 ! ,secret>y1 tak+ into acc\nt 
! results ( ! /udy conduct$ by !        
,comptroll] ,g5]al ( ! ,unit$ ,/ates "u 
section #h7;a77#c7 ( ! ,quality ,c>e =  
,nurs+ ,home ,resid5ts ,act ( #bjai & 9 
consultation ) /akehold] gr\ps 7includ+ 
resid5ts ( skill$ nurs+ facilities1     
family memb]s ( su* resid5ts1 advocates 

= su* resid5ts1 long-t]m c>e ombudsm51 &
 provid]s71 %all develop a /&>diz$      
protocol = nurs+ facilities to obta9    
writt5 in=m$ cons5t1 9 accordance ) ?is 
p>agraph1 f a resid5t 7or1 if           
applicable1 ! resid5t's designat$ heal? 
c>e ag5t or o!r surrogate "u ,/ate law  
or regulation7 prior to prescrib+ a     
psy*otropic drug to ! resid5t = a use n 
approv$ by ! ,food & ,drug              
,adm9i/ration4  7,b7 ,requirem5ts ,!    
/&>diz$ protocol develop$ "u subp>agraph
 7,a7 %all include ! foll[+3 7i7 ,a     
requirem5t1 ) respect to a resid5t1 t-- 
7,i7 ! facility1 ) ! involvem5t ( !     
prescrib]1 in=m ! resid5t 7or1 if       
applicable1 ! resid5t's designat$ heal? 
c>e ag5t or o!r surrogate "u ,/ate law  
or regulation7 (--  7aa7 possible side  
effects & risks associat$ ) !           
psy*otropic drug1 includ+ ! m5tion ( any
 black box w>n+2  7bb7 treatm5t         
modalities t 7 attempt$ prior to ! use (
 ! psy*otropic drug2 &  7cc7 any o!r    
in=mation ! ,secret>y det]m9es          

appropriate2  7,,ii7 ! resid5t 7or1 if  
applicable1 ! resid5t's designat$ heal? 
c>e ag5t or o!r surrogate "u ,/ate law  
or regulation7 provide writt5 in=m$     
cons5t to ! adm9i/ration ( ! psy*otropic
 drug2 &  7,,iii7 ! adm9i/ration ( !    
psy*otropic drug is 9 accordance ) any  
plan ( c>e t ! resid5t has 9 place1     
includ+ non-ph>macological int]v5tions z
 appropriate t c effectively address    
und]ly+ m$ical & environm5tal causes (  
behavioral disord]s4  7ii7 ,an          
alt]native protocol = obta9+ su* writt5 
in=m$ cons5t-- 7,i7 9 ! case (          
em]g5cies2 &  7,,ii7 9 ! abs5ce ( a     
cle>ly id5tifi$ designat$ heal? c>e ag5t
 or o!r surrogate "u ,/ate law or       
regulation4  7iii7 ,o!r items det]m9$   
appropriate by ! ,secret>y4  7,c7 ,tim+ 
( in=m$ cons5t ,"u ! /&>diz$ protocol1 a
 nurs+ facility %all obta9 ! writt5     
in=m$ cons5t describ$ 9 subp>agraph     
7,a71 ) respect to a psy*otropic drug & 
a resid5t ( ! facility--  7i7 prior to !
 initial prescrib+ ( su* psy*otropic    

drug to su* resid5t if su* resid5t does 
n h a curr5t prescription = su*         
psy*otropic drug at ! "t su* resid5t is 
admitt$ to ! facility2 &  7ii7 at lea/  
once a mon? to ! ext5t t ! adm9i/ration 
( su* psy*otropic drug to su* resid5t is
 9 accordance ) ! plan ( c>e t ! resid5t
 has 9 place4  7,d7 ,compliance         
,effective beg9n+ on ! date t is "o ye> 
& #ahj days aft] ! date ( ! enactm5t (  
?is p>agraph1 a nurs+ facility %all     
comply ) ! /&>diz$ protocol develop$ "u 
subp>agraph 7,a74  7,e7 ,no preemption  
,no?+ 9 ?is p>agraph %all preempt any   
provision ( ,/ate or ,f$]al law t       
provides broad] rights ) respect to     
writt5 in=m$ cons5t = resid5ts (        
facilities4  4  7#c7 ,,gao /udy & report
 on in=m$ cons5t laws ) respect to      
prescrib+ ( psy*otropic drugs  7,a7     
,/udy ,! ,comptroll] ,g5]al ( ! ,unit$  
,/ates 79 ?is p>agraph ref]r$ to z !    
,comptroll] ,g5]al7 %all conduct a /udy 
( ,/ate laws & regulations conc]n+ in=m$
 cons5t ) respect to ! adm9i/ration ( a 

psy*otropic drug ) reg>d to !           
effectiv5ess ( su* laws & practices 9   
*ang+ ! frequ5cy ( prescrib+ (          
psy*otropic drugs to old] adults4 ,!    
/udy %all include an analysis z to :e!r 
9 ! case ( ,/ates t h n enact$ su* in=m$
 cons5t laws1 su* ,/ates h develop$ o!r 
me*anisms to guide appropriate prescrib+
 ( psy*otropic drugs 9 old] adults )    
dem5tia4  7,b7 ,report ,n lat] ?an #ahj 
days aft] ! date ( enactm5t ( ?is ,act1 
! ,comptroll] ,g5]al %all submit to !   
,secret>y ( ,heal? & ,human ,s]vices &  
to ,congress a report conta9+ ! results 
( ! /udy conduct$ "u subp>agraph 7,a71  
toge!r ) su* recomm5dations z !         
,comptroll] ,g5]al det]m9es appropriate4
  7b7 ,developm5t ( measure (           
utilization ( psy*otropic drugs =       
inclusion on ,nurs+ ,home ,comp>e       
website  7#a7 ,m$ic>e ,section #ahai7;i7
 ( ! ,social ,security ,act 7#db        
,u4,s4,c4 #acie;i-#c7;i77 is am5d$--    
7,a7 by r$esignat+ p>agraph 7#c7 z      
p>agraph 7#d72 &  7,b7 by ins]t+ aft]   

p>agraph 7#b7 ! foll[+ new p>agraph3    
7#c7 ,developm5t ( measure ( utilization
 ( psy*otropic drugs  7,a7 ,9 g5]al ,n  
lat] ?an ! date t is "o ye> aft] ! date 
( ! enactm5t ( ?is p>agraph1 ! ,secret>y
 %all include a measure ( ! utilization 
( psy*otropic drugs = ea* skill$ nurs+  
facility = inclusion on su* website 7or 
a successor website7 z "p ( ! quality   
measures or heal? inspections measures1 
or bo? su* measures1 "u ! ,five-,/>     
,quality ,rat+ ,sy/em e/abli%$ by !     
,adm9i/rator ( ! ,c5t]s = ,m$ic>e       
,m$icaid ,s]vices4  7,b7 ,consid]ations 
,9 develop+ ! measure "u subp>agraph    
7,a71 ! ,secret>y %all take into acc\nt 
special pati5t populations1 special c>e 
units1 appropriate diagnoses1 & o!r     
factors1 z det]m9$ appropriate by !     
,secret>y4  4  7#b7 ,m$icaid ,section   
#aiai7;i7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #acifr7i77 is am5d$--    
7,a7 by r$esignat+ p>agraph 7#c7 z      
p>agraph 7#d72 &  7,b7 by ins]t+ aft]   
p>agraph 7#b7 ! foll[+ new p>agraph3    

7#c7 ,developm5t ( measure ( utilization
 ( psy*otropic drugs  7,a7 ,9 g5]al ,n  
lat] ?an ! date t is "o ye> aft] ! date 
( ! enactm5t ( ?is p>agraph1 ! ,secret>y
 %all include a measure ( ! utilization 
( psy*otropic drugs = ea* nurs+ facility
 = inclusion on su* website 7or a       
successor website7 z "p ( ! quality     
measures or heal? inspections measures1 
or bo? su* measures1 "u ! ,five-,/>     
,quality ,rat+ ,sy/em e/abli%$ by !     
,adm9i/rator ( ! ,c5t]s = ,m$ic>e       
,m$icaid ,s]vices4  7,b7 ,consid]ations 
,9 develop+ ! measure "u subp>agraph    
7,a71 ! ,secret>y %all take into acc\nt 
special pati5t populations1 special c>e 
units1 appropriate diagnoses1 & o!r     
factors1 z det]m9$ appropriate by !     
,secret>y4  4