,,ii  #aaf? ,,congress  #b;d ,session   
,s4 #dhff  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,octob] #bf            
7legislative day1 ,octob] #ai71         
#bjbj,mr4 ,casey 7= himself & ,mr4      
,toomey7 introduc$ ! foll[+ bill2 :i* 0 
read twice & ref]r$ to ! ,committee on  
,f9ance  ,a ,,bill  ,to am5d titles     
,,xviii & ,,xix ( ! ,social ,security   
,act to mod]nize ,f$]al nurs+ home      
protections & to enhance c>e quality &  
transp>5cy = nurs+ home resid5ts & _!   
families4  #a4 ,%ort title ,?is ,act may
 be cit$ z ! ,nurs+ ,home ,re=m         
,mod]nization ,act ( #bjbj4  #b4        
,improvem5ts to nurs+ facilities "u !   
,m$ic>e & ,m$icaid programs  7a7        
,advisory ,c\ncil on ,skill$ ,nurs+     
,facility ,rank+s ,"u ,m$ic>e & ,nurs+  
,facility ,rank+s ,"u ,m$icaid  7#a7    
,e/abli%m5t ,n lat] ?an #a ye> aft] !   
date ( enactm5t ( ?is ,act1 ! ,secret>y 
( ,heal? & ,human ,s]vices %all e/abli% 
! ,advisory ,c\ncil on ,skill$ ,nurs+   
,facility ,rank+s ,"u ,m$ic>e & ,nurs+  

,facility ,rank+s ,"u ,m$icaid 79 ?is   
subsection ref]r$ to z ! ,advisory      
,c\ncil74  7#b7 ,memb]%ip ,! ,secret>y  
%all ensure t ! memb]%ip ( ! ,advisory  
,c\ncil includes equal repres5tation f !
 foll[+3 7,a7 ,consum]s ) nurs+ home    
exp]i5ce1 includ+ adults age #fe & old]1
 individuals ) disabilities1 family     
c>egiv]s1 & _! advocates4  7,b7 ,skill$ 
nurs+ facilities & nurs+ facilities1    
includ+ nonpr(it facilities4  7,c7      
,academics ) exp]tise 9 nurs+ home      
ov]sight4  7,d7 ,heal? pr(essionals )   
nurs+ home exp]i5ce1 su* z physicians1  
nurses1 ph>maci/s1 c]tifi$ nurs+        
assi/ants1 & direct c>e pr(essionals4   
7,e7 ,pr(essionals ) exp]tise 9 quality 
measurem5t4  7,f7 ,pr(essionals )       
exp]tise 9 em]g5cy managem5t4  7,g7     
,/ate survey+ ag5cies4  7,h7 ,/ate      
long-t]m c>e ombudsman programs4  7,i7  
,! ,m$ic>e ,paym5t ,advisory            
,commission4  7,j7 ,! ,m$icaid & ,,*ip  
,paym5t & ,access ,commission4  7,k7 ,! 
,c5t]s = ,m$ic>e  ,m$icaid ,s]vices4    

7,l7 ,o!r repres5tatives z ! ,secret>y  
det]m9es appropriate4  7#c7 ,duties     
7,a7 ,/udy ,! ,advisory ,c\ncil %all    
conduct a /udy ( processes = rank+      
skill$ nurs+ facilities & nurs+         
facilities "u p>agraph 7#i7 ( section   
#ahai7;f7 ( ! ,social ,security ,act1 z 
add$ by subsection 7b77#a7 & "u p>agraph
 7#aa7 ( section #aiai7;f7 ( su* ,act1 z
 add$ by subsection 7c77#a74 ,su* /udy  
%all include an analysis (-- 7i7 :i*    
available1 v]ifiable data s\rces &      
measures are be/ = appropriately        
designat+ facilities 9-- 7,i7 !         
high-rat$ facility program "u p>agraph  
7#aj7 ( su* section #ahai7;f7 & "u      
p>agraph 7#ab7 ( su* section #aiai7;f72 
&  7,,ii7 ! l[-rat$ facility program "u 
p>agraph 7#h7 ( su* section #ahai7;f7 & 
"u p>agraph 7#aj7 ( su* section         
#aiai7;f72  7ii7 ! appropriate frequ5cy 
) :i* to update ! rank+s = ! high-rat$ &
 l[-rat$ facility programs describ$ 9   
clause 7i72  7iii7 h[ be/ to ensure t   
skill$ nurs+ facilities & nurs+         

facilities appropriately report adv]se  
ev5ts2  7iv7 h[ surveyors c cle>ly      
provide ! rationale = giv+ defici5cies  
to su* skill$ nurs+ facilities & nurs+  
facilities & h[ ?is c be done 9 a timely
 mann]2  7v7 h[ to manage susp5sions f !
 high-rat$ facility program describ$ 9  
clause 7i77,i7 & ! ne$ = additional     
consum] protections to adm9i/] su*      
high-rat$ facility program2  7vi7 !     
availability or pot5tial developm5t (1  
or modifications to1 measures or        
v]ifiable data s\rces on topics1 includ+
 avoidable hospital readmissions1       
em]g5cy room visits1 risk-adju/$        
mortality1 dis*>ges to ! community1     
involunt>y dis*>ges1 situations involv+ 
! inappropriate adm9i/ration (          
m$ications by a facility1 & em]g5cy     
managem5t2 &  7vii7 ! developm5t (1 or  
modifications to1 data collection1      
v]ifiable data s\rces1 & pot5tial       
measures to assess ! f9ancial /ability (
 a facility4  7,b7 ,f9d+s &             
recomm5dations  7i7 ,9 g5]al ,n lat] ?an

 #b ye>s aft] ! date ( enactm5t ( ?is   
,act1 ! ,advisory ,c\ncil %all submit to
 ! ,secret>y ! f9d+s ( ! ,advisory      
,c\ncil "u ! /udy conduct$ "u           
subp>agraph 7,a71 toge!r )              
recomm5dations = su* legislation &      
adm9i/rative action z ! ,advisory       
,c\ncil det]m9es appropriate4  7ii7     
,public availability ,^u receiv+ ! f9d+s
 & recomm5dations "u clause 7i71 !      
,secret>y %all make ! f9d+s &           
recomm5dations available to ! public on 
! int]net website ( ! ,c5t]s = ,m$ic>e  
,m$icaid ,s]vices4  7#d7 ,sunset ,!     
,advisory ,c\ncil %all t]m9ate ^u !     
submission ( ! report to ! ,secret>y "u 
p>agraph 7#c77;,b77i74  7b7 ,m$ic>e     
program revisions  7#a7 ,e/abli%m5t (   
rank+s & high-rat$ facility program     
7,a7 ,9 g5]al ,section #ahai7;f7 ( !    
,social ,security ,act 7#db ,u4,s4,c4   
#acie;i-#c7;f77 is am5d$ by add+ at !   
end ! foll[+ new p>agraphs3  7#i7 ,rank+
 process  7,a7 ,process  7i7 ,e/abli%m5t
 ,! ,secret>y %all e/abli% a process to 

rank skill$ nurs+ facilities bas$ on    
compliance ) ! applicable requirem5ts ( 
?is ,act4  7ii7 ,data ,! process        
e/abli%$ "u clause 7i7 %all include !   
use ( at lea/ ! prec$+ #c ye>s ( heal?  
inspection data1 if appropriate1 & o!r  
data z det]m9$ appropriate by !         
,secret>y4  7iii7 ,f9d+s &              
recomm5dations ( ! ,advisory ,c\ncil on 
,skill$ ,nurs+ ,facility ,rank+s "u     
,m$ic>e & ,nurs+ ,facility ,rank+s "u   
,m$icaid ,9 e/abli%+ ! process "u clause
 7i71 ! ,secret>y %all take into acc\nt 
! f9d+s & recomm5dations ( ! ,advisory  
,c\ncil t are submitt$ to ! ,secret>y "u
 section #b7;a77#c77;,b77i7 ( ! ,nurs+  
,home ,re=m ,mod]nization ,act ( #bjbj4 
7,b7 ,rank+  7i7 ,9 g5]al ,"u ! process 
e/abli%$ "u subp>agraph 7,a71 !         
,secret>y %all use ! rank+s ( skill$    
nurs+ facilities to categorize          
facilities into highe/ & l[e/ gr\ps = ! 
purposes specifi$ 9 clause 7ii74  7ii7  
,tim+ & use ( rank+s ,n lat] ?an #b ye>s
 aft] ! date ! ,secret>y receives !     

f9d+s & recomm5dations describ$ 9       
subp>agraph 7,a77iii71 ! ,secret>y %all 
use ! rank+s "u clause 7i7 = purposes ( 
c>ry+ out-- 7,i7 ! high-rat$ facility   
program "u p>agraph 7#aj72 &  7,,ii7 !  
l[-rat$ facility program "u p>agraph    
7#h74  7#aj7 ,high-rat$ facility program
  7,a7 ,e/abli%m5t  7i7 ,9 g5]al ,n lat]
 ?an #b ye>s aft] ! date ! ,secret>y    
receives ! f9d+s & recomm5dations       
describ$ 9 p>agraph 7#i77;,a77iii71 !   
,secret>y %all e/abli% & implem5t a     
high-rat$ facility program to enc\rage &
 rew>d compliance ) ! requirem5ts ( ?is 
,act4  7ii7 ,report ,9 e/abli%+ !       
high-rat$ facility program1 ! ,secret>y 
%all take into acc\nt ! f9d+s &         
recomm5dations describ$ 9 p>agraph      
7#i77;,a77iii74  7iii7 ,regulations ,!  
,secret>y %all e/abli% ! high-rat$      
facility program "u clause 7i7 ?r\gh    
notice & comm5t rulemak+4  7,b7         
,designation ,"u ! high-rat$ facility   
program1 subject to subp>agraph 7,d71 ! 
,secret>y %all designate ! highe/ rat$  

skill$ nurs+ facilities "u ! rank+s "u  
p>agraph 7#i77;,b7 z high-rat$ skill$   
nurs+ facilities4  7,c7 ,di/9ction on   
,nurs+ ,home ,comp>e website ,a skill$  
nurs+ facility t is designat$ z a       
high-rat$ skill$ nurs+ facility "u      
subp>agraph 7,b7 %all receive a         
high-rat$ di/9ction on ! (ficial        
,int]net website ( ! ,f$]al ,gov]nm5t = 
comp>+ nurs+ homes pursuant to          
subsection 7i77#a77;,c74  7,d7          
,susp5sion ( high-rat$ /atus  7i7 ,9    
g5]al ,! ,secret>y %all susp5d a skill$ 
nurs+ facility's designation "u         
subp>agraph 7,b7 if ! ,secret>y det]m9es
 t !re are circum/ances w>rant+ su*     
susp5sion4  7ii7 ,circum/ances ,9       
e/abli%+ ! circum/ances "u clause 7i71 !
 ,secret>y %all take into acc\nt-- 7,i7 
f9d+s f ,f$]al surveys & inve/igations2 
7,,ii7 f9d+s f ,/ate surveys conduct$ "u
 subsection 7g77#b77;,a72  7,,iii7 f9d+s
 f ,/ate inve/igations & surveys        
conduct$ "u subsection 7g77#d71 includ+ 
a high numb] ( sub/antiat$ compla9ts1 ! 

frequ5cy & sev]ity ( sub/antiat$        
compla9ts1 & h[ ! compla9ts are h&l$ by 
! facility2  7,,iv7 situations involv+  
*anges ( own]%ip1 adm9i/ration1 or      
managem5t ( a skill$ nurs+ facility1 or 
! director ( nurs+2  7,v7 situations    
involv+ ! inappropriate adm9i/ration (  
m$ications by a facility2  7,,vi7       
situations involv+ involunt>y dis*>ges (
 resid5ts2 &  7,,vii7 o!r factors       
det]m9$ appropriate by ! ,secret>y4     
7iii7 ,no re9/atem5t prior to next /&>d 
survey ,if a skill$ nurs+ facility's    
designation is susp5d$ "u clause 7i71   
su* designation %all n be re9/at$ prior 
to a subsequ5t survey z specifi$ "u     
subsection 7g77#b77;,a77iii74  4  7,b7  
,assessm5t ( high-rat$ designation 9    
special surveys ,section                
#ahai7;g77#b77;,a77iii77,,ii7 ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#acie;i-#c7;g77#b77;,a77iii77,,ii77 is  
am5d$-- 7i7 by ins]t+ 7or1 9 ! case ( a 
facility t is designat$ z a high-rat$   
skill$ nurs+ facility "u subsection     

7f77#aj71 %all be conduct$7 aft] may be 
conduct$2 &  7ii7 by add+ at ! end !    
foll[+ new s5t5ce3 ,on & aft] ! date !  
,secret>y implem5ts ! high-rat$ facility
 program "u subsection 7f77#aj71 any    
survey conduct$1 pursuant to ! prec$+   
s5t5ce1 ( a facility t is designat$ z a 
high-rat$ skill$ nurs+ facility "u su*  
subsection %all include an assessm5t (  
:e!r su* designation %\ld cont9ue or be 
susp5d$ "u subp>agraph 7,d7 ( su*       
subsection44  7#b7 ,improvem5ts to !    
special focus facility program  7,a7    
,appropriate p>ticipation ,section      
#ahai7;f77#h7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acie;i-#c7;f77#h77 is  
am5d$-- 7i7 9 subp>agraph 7,a71 by /rik+
 ,! ,secret>y & ins]t+ ,subject to !    
succe$+ provisions ( ?is subsection1 !  
,secret>y2 &  7ii7 by add+ at ! end !   
foll[+ new subp>agraph3  7,c7           
,appropriate p>ticipation ,n lat] ?an #a
 ye> aft] ! date ( enactm5t ( ! ,nurs+  
,home ,re=m ,mod]nization ,act ( #bjbj1 
! ,secret>y %all ensure t ! numb] (     

facilities p>ticipat+ 9 ! special focus 
facility program is n less ?an #c4e     
p]c5t ( all skill$ nurs+ facilities4  4 
7,b7 ,conv]sion ( ! special focus       
facility program to ! l[-rat$ facility  
program & additional requirem5ts        
,section #ahai7;f77#h7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acie;i-#c7;f77#h771 z am5d$ by         
subp>agraph 7,a71 is am5d$-- 7i7 9      
subp>agraph 7,b71 by ins]t+ ! foll[+    
be=e ! p]iod at ! end3 7or1 on & aft] ! 
date ! ,secret>y makes ! conv]sion      
describ$ 9 subp>agraph 7,d71 at a       
frequ5cy det]m9$ appropriate by !       
,secret>y 7b 9 no case less ?an once e  
#f mon?s772 &  7ii7 by add+ at ! end !  
foll[+ new subp>agraphs3  7,d7          
,conv]sion to ! l[-rat$ facility program
  7i7 ,9 g5]al ,on ! same date t !      
,secret>y implem5ts ! high-rat$ facility
 program "u p>agraph 7#aj71 ! ,secret>y 
%all conv]t ! special focus facility    
program "u ?is subsection to ! l[-rat$  
facility program4  7ii7 ,regulations ,! 

,secret>y %all c>ry out ! conv]sion "u  
clause 7i7 ?r\gh notice & comm5t        
rulemak+4  7iii7 ,additional requirem5ts
 = ! l[-rat$ facility program ,9        
addition to ! provisions t apply to !   
l[-rat$ facility program ?r\gh !        
conv]sion f ! special focus facility    
program1 ! succe$+ provisions ( ?is     
subsection %all also apply to ! l[-rat$ 
facility program4  7,e7 ,p>ticipation   
,subject to ! m9imum p>ticipation       
requirem5t "u subp>agraph 7,c71 !       
,secret>y %all designate ! l[e/ rat$    
skill$ nurs+ facilities "u ! rank+s "u  
p>agraph 7#i77;,b7 = p>ticipation 9 !   
l[-rat$ facility program4  7,f7         
,progressive en=cem5t actions ,!        
,secret>y1 9 consultation ) ,/ates1 %all
 utilize progressive en=cem5t actions1 (
 increas+ sev]ity1 to ensure facilities 
p>ticipat+ 9 ! l[-rat$ facility program 
meet ! applicable requirem5ts "u ?is    
,act4  7,g7 ,en=cem5t = patt]ns (       
defici5cy ,! ,secret>y may utilize      
en=cem5t actions specifi$ 9 subsection  

7h77#b7 to rem$y patt]ns ( defici5cies  
cit$ across multiple surveys4  7,h7     
,compliance assi/ance programs  7i7     
,on-site consultation & educational     
programm+  7,i7 ,9 g5]al ,! ,secret>y   
%all e/abli% on-site consultation &     
educational programm+ = skill$ nurs+    
facilities p>ticipat+ 9 ! l[-rat$       
facility program ) respect to compliance
 ) ! applicable requirem5ts "u ?is ,act4
  7,,ii7 ,entity ,! on-site consultation
 & educational programm+ describ$ 9     
subclause 7,i7 %all be c>ri$ out by     
quality improvem5t organizations "u "p  
,b ( title ,,xi or o!r indep5d5t        
organizations ( a simil> type t d n h   
conflicts ( int]e/ & are deem$          
appropriate by ! ,secret>y4  7,,iii7    
,requir$ p>ticipation ,a skill$ nurs+   
facility p>ticipat+ 9 ! l[-rat$ facility
 program %all p>ticipate 9 any          
consultations & educational programm+   
describ$ 9 subclause 7,i7 conduct$ at ! 
facility4  7ii7 ,consultation indep5d5t 
( en=cem5t  7,i7 ,9 g5]al ,subject to   

subclause 7,,ii71 on-site consultations 
& educational programm+ describ$ 9      
clause 7i7 %all be conduct$ indep5d5tly 
( any en=cem5t activity4  7,,ii7        
,exception ,subclause 7,i7 %all n apply 
9 ! case :]e a trigg]+ ev5t at ! skill$ 
nurs+ facility is obs]v$ 9 ! c\rse (    
provid+ on-site consultations &         
educational programm+ describ$ 9 clause 
7i74 ,9 e/abli%+ su* on-site            
consultations & educational programm+1 !
 ,secret>y %all det]m9e ! trigg]+ ev5ts 
= :i* ! use ( necess>y en=cem5t actions 
is p]mitt$ not)/&+ ! limitation "u      
subclause 7,i74 ,su* trigg]+ ev5ts %all 
include ev5ts t are requir$ to be       
report$ "u ,/ate & ,f$]al law & a patt]n
 ( defici5cies or problems t ! quality  
improvem5t organization or o!r          
organization has id5tifi$ = correction b
 :i* are consi/5tly n correct$4  7,i7   
,public availability  7i7 ,9 g5]al ,!   
,secret>y %all ensure t a skill$ nurs+  
facility's p>ticipation 9 ! l[-rat$     
facility program is publicly ann\nc$1   

includ+ to-- 7,i7 resid5t family        
c\ncils2  7,,ii7 resid5t att5d+         
physicians2  7,,iii7 ! ,/ate bo>d       
responsible = ! lic5s+ ( ! skill$ nurs+ 
facility adm9i/rator at ! facility2     
7,,iv7 ,/ate ,long-,t]m ,c>e ,ombudsman 
programs 7z describ$ 9 section          
#gab7;a77#a7 ( ! ,old] ,am]icans ,act ( 
#aife72 &  7,v7 ! community at l>ge4    
7ii7 ,writt5 notification ,! ,secret>y  
%all ensure t1 9 ! case ( a skill$ nurs+
 facility t is p>ticipat+ 9 ! l[-rat$   
facility program1 resid5ts ( su*        
facility & family or legal              
repres5tatives are furni%$ )            
individualiz$ writt5 notice ( su*       
p>ticipation4 ,su* notice %all be       
provid$ to curr5t resid5ts & to new     
resid5ts prior to admission4  7,j7      
,requirem5t = removal ,! ,secret>y %all 
require t a skill$ nurs+ facility %[    
improvem5t prior to removal f ! l[-rat$ 
facility program4  4  7,c7 ,use ( civil 
money p5alties ,section                 
#ahai7;h77#b77;,b77ii77,,iv77ff7 ( !    

,social ,security ,act 7#db ,u4,s4,c4   
#acie;i-#c7;h77#b77;,b77ii77,,iv77ff77  
is am5d$-- 7i7 by /rik+ & facility      
improvem5t initiatives & ins]t+ facility
 improvem5t initiatives2 &  7ii7 by     
ins]t+ ! foll[+ be=e ! p]iod at ! end3 1
 &1 on & aft] ! date ! ,secret>y makes !
 conv]sion describ$ 9 subsection        
7f77#h77;,d71 consultation1 education1 &
 o!r activities to fo/] improvem5t &    
rem$y root causes contribut+ to         
defici5cies cit$ across multiple surveys
 among facilities 9 ! l[-rat$ facility  
program "u subsection 7f77#h74  7#c7    
,in=mation on high-rat$ & l[-rat$       
facilities on ,nurs+ ,home ,comp>e      
,m$ic>e website ,section #ahai7;i77#a7 (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #acie;i-#c7;i77#a77 is am5d$-- 7,a7 9  
subp>agraph 7,a71 by add+ at ! end !    
foll[+ new clause3  7vi7 ,on & aft] !   
date ! ,secret>y implem5ts ! high-rat$  
facility program "u subsection 7f77#aj7 
& makes ! conv]sion "u subsection       
7f77#h77;,d71 consi/5t ) subp>agraph    

7,c7-- 7,i7 = ea* skill$ nurs+ facility 
t is designat$ z a high-rat$ skill$     
nurs+ facility "u subsection 7f77#aj71 !
 date ! facility 0 s designat$2 &       
7,,ii7 = ea* skill$ nurs+ facility      
p>ticipat+ 9 ! l[-rat$ facility program 
"u subsection 7f77#h71 ! date ! facility
 0 id5tifi$ = inclusion 9 su* program4  
2 &  7,b7 by add+ at ! end ! foll[+ new 
subp>agraphs3  7,c7 ,di/9ctions =       
high-rat$ & l[-rat$ facilities ,on &    
aft] ! date ! ,secret>y implem5ts !     
high-rat$ facility program "u subsection
 7f77#aj7 & makes ! conv]sion "u        
subsection 7f77#h77;,d71 ! ,secret>y    
%all ensure t graphics1 includ+ an      
appropriate explanation ( su* graphics1 
are prom95tly display$ on ! website     
describ$ 9 subp>agraph 7,a7 9 ord] to   
di/+ui% ea* ( ! foll[+3 7i7 ,skill$     
nurs+ facilities t are designat$ z      
high-rat$ skill$ nurs+ facilities "u    
subsection 7f77#aj74  7ii7 ,skill$ nurs+
 facilities t are p>ticipat+ 9 ! l[-rat$
 facility program "u subsection 7f77#h71

 ) in=mation on facilities t h be5 plac$
 9 su* program m ?an "o "t ov] ! c\rse (
 ! la/ #aj ye>s 7includ+ ! numb] ( times
 su* skill$ nurs+ facilities h be5 plac$
 9 ! program74  7,d7 ,focus gr\ps &     
consum] te/+ ,9 ord] to help limit      
confusion1 p>ticul>ly among old] adults1
 individuals ) disabilities1 & family   
c>egiv]s1 ! ,secret>y %all utilize focus
 gr\ps & o!r consum] te/+ me?ods prior  
to includ+ ! additional in=mation "u    
subp>agraph 7,a77vi7 & implem5t+ !      
di/9ctions "u subp>agraph 7,c74  4  7c7 
,m$icaid program revisions  7#a7        
,e/abli%m5t ( rank+s & high-rat$        
facility program  7,a7 ,9 g5]al ,section
 #aiai7;f7 ( ! ,social ,security ,act   
7#db ,u4,s4,c4 #acifr7f77 is am5d$ by   
add+ at ! end ! foll[+ new p>agraphs3   
7#aa7 ,rank+ process  7,a7 ,process  7i7
 ,e/abli%m5t ,! ,secret>y %all e/abli% a
 process to rank nurs+ facilities bas$  
on compliance ) ! applicable requirem5ts
 ( ?is ,act4  7ii7 ,data ,! process     
e/abli%$ "u clause 7i7 %all include !   

use ( at lea/ ! prec$+ #c ye>s ( heal?  
inspection data1 if appropriate1 & o!r  
data z det]m9$ appropriate by !         
,secret>y4  7iii7 ,f9d+s &              
recomm5dations ( ! ,advisory ,c\ncil on 
,skill$ ,nurs+ ,facility ,rank+s "u     
,m$ic>e & ,nurs+ ,facility ,rank+s "u   
,m$icaid ,9 e/abli%+ ! process "u clause
 7i71 ! ,secret>y %all take into acc\nt 
! f9d+s & recomm5dations ( ! ,advisory  
,c\ncil t are submitt$ to ! ,secret>y "u
 section #b7;a77#c77;,b77i7 ( ! ,nurs+  
,home ,re=m ,mod]nization ,act ( #bjbj4 
7,b7 ,rank+  7i7 ,9 g5]al ,"u ! process 
e/abli%$ "u subp>agraph 7,a71 !         
,secret>y %all use ! rank+s ( nurs+     
facilities to categorize facilities into
 highe/ & l[e/ gr\ps = ! purposes       
specifi$ 9 clause 7ii74  7ii7 ,tim+ &   
use ( rank+s ,n lat] ?an #b ye>s aft] ! 
date ! ,secret>y receives ! f9d+s &     
recomm5dations describ$ 9 subp>agraph   
7,a77iii71 ! ,secret>y %all use ! rank+s
 "u clause 7i7 = purposes ( c>ry+ out-- 
7,i7 ! high-rat$ facility program "u    

p>agraph 7#ab72 &  7,,ii7 ! l[-rat$     
facility program "u p>agraph 7#aj74     
7#ab7 ,high-rat$ facility program  7,a7 
,e/abli%m5t  7i7 ,9 g5]al ,n lat] ?an #b
 ye>s aft] ! date ! ,secret>y receives !
 f9d+s & recomm5dations describ$ 9      
p>agraph 7#aa77;,a77iii71 ! ,secret>y   
%all e/abli% & implem5t a high-rat$     
facility program to enc\rage & rew>d    
compliance ) ! requirem5ts ( ?is ,act4  
7ii7 ,report ,9 e/abli%+ ! high-rat$    
facility program1 ! ,secret>y %all take 
into acc\nt ! f9d+s & recomm5dations    
describ$ 9 p>agraph 7#aa77;,a77iii74    
7iii7 ,regulations ,! ,secret>y %all    
e/abli% ! high-rat$ facility program "u 
clause 7i7 ?r\gh notice & comm5t        
rulemak+4  7,b7 ,designation ,"u !      
high-rat$ facility program1 subject to  
subp>agraph 7,d71 ! ,secret>y %all      
designate ! highe/ rat$ nurs+ facilities
 "u ! rank+s "u p>agraph 7#aa77;,b7 z   
high-rat$ nurs+ facilities4  7,c7       
,di/9ction on ,nurs+ ,home ,comp>e      
website ,a nurs+ facility t is designat$

 z a high-rat$ nurs+ facility "u        
subp>agraph 7,b7 %all receive a         
high-rat$ di/9ction on ! (ficial        
,int]net website ( ! ,f$]al ,gov]nm5t = 
comp>+ nurs+ homes pursuant to          
subsection 7i77#a77;,c74  7,d7          
,susp5sion ( high-rat$ /atus  7i7 ,9    
g5]al ,! ,secret>y %all susp5d a nurs+  
facility's designation "u subp>agraph   
7,b7 if ! ,secret>y det]m9es t !re are  
circum/ances w>rant+ su* susp5sion4     
7ii7 ,circum/ances ,9 e/abli%+ !        
circum/ances "u clause 7i71 ! ,secret>y 
%all take into acc\nt-- 7,i7 f9d+s f    
,f$]al surveys & inve/igations2  7,,ii7 
f9d+s f ,/ate surveys conduct$ "u       
subsection 7g77#b77;,a72  7,,iii7 f9d+s 
f ,/ate inve/igations & surveys conduct$
 "u subsection 7g77#d71 includ+ a high  
numb] ( sub/antiat$ compla9ts1 !        
frequ5cy & sev]ity ( sub/antiat$        
compla9ts1 & h[ ! compla9ts are h&l$ by 
! facility2  7,,iv7 situations involv+  
*anges ( own]%ip1 adm9i/ration1 or      
managem5t ( a nurs+ facility1 or !      

director ( nurs+2  7,v7 situations      
involv+ ! inappropriate adm9i/ration (  
m$ications by a facility2  7,,vi7       
situations involv+ involunt>y dis*>ges (
 resid5ts2 &  7,,vii7 o!r factors       
det]m9$ appropriate by ! ,secret>y4     
7iii7 ,no re9/atem5t prior to next /&>d 
survey ,if a nurs+ facility's           
designation is susp5d$ "u clause 7i71   
su* designation %all n be re9/at$ prior 
to a subsequ5t survey z specifi$ "u     
subsection 7g77#b77;,a77iii74  4  7,b7  
,assessm5t ( high-rat$ designation 9    
special surveys ,section                
#aiai7;g77#b77;,a77iii77,,ii7 ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#acifr7g77#b77;,a77iii77,,ii77 is       
am5d$-- 7i7 by ins]t+ 7or1 9 ! case ( a 
facility t is designat$ z a high-rat$   
nurs+ facility "u subsection 7f77#ab71  
%all be conduct$7 aft] may be conduct$2 
&  7ii7 by add+ at ! end ! foll[+ new   
s5t5ce3 ,on & aft] ! date ! ,secret>y   
implem5ts ! high-rat$ facility program  
"u subsection 7f77#ab71 any survey      

conduct$1 pursuant to ! prec$+ s5t5ce1 (
 a facility t is designat$ z a high-rat$
 nurs+ facility "u su* subsection %all  
include an assessm5t ( :e!r su*         
designation %\ld cont9ue or be susp5d$  
"u subp>agraph 7,d7 ( su* subsection44  
7#b7 ,improvem5ts to ! special focus    
facility program  7,a7 ,appropriate     
p>ticipation ,section #aiai7;f77#aj7 ( !
 ,social ,security ,act 7#db ,u4,s4,c4  
#acier7f77#aj77 is am5d$-- 7i7 9        
subp>agraph 7,a71 by /rik+ ,! ,secret>y 
& ins]t+ ,subject to ! succe$+          
provisions ( ?is subsection1 !          
,secret>y2 &  7ii7 by add+ at ! end !   
foll[+ new subp>agraph3  7,c7           
,appropriate p>ticipation ,n lat] ?an #a
 ye> aft] ! date ( enactm5t ( ! ,nurs+  
,home ,re=m ,mod]nization ,act ( #bjbj1 
! ,secret>y %all ensure t ! numb] (     
facilities p>ticipat+ 9 ! special focus 
facility program is n less ?an #c4e     
p]c5t ( all nurs+ facilities4  4  7,b7  
,conv]sion ( ! special focus facility   
program to ! l[-rat$ facility program & 

additional requirem5ts ,section         
#aiai7;f77#aj7 ( ! ,social ,security    
,act 7#db ,u4,s4,c4                     
#acie;i-#c7;f77#aj771 z am5d$ by        
subp>agraph 7,a71 is am5d$-- 7i7 9      
subp>agraph 7,b71 by ins]t+ ! foll[+    
be=e ! p]iod at ! end3 7or1 on & aft] ! 
date ! ,secret>y makes ! conv]sion      
describ$ 9 subp>agraph 7,d71 at a       
frequ5cy det]m9$ appropriate by !       
,secret>y 7b 9 no case less ?an once e  
#f mon?s772 &  7ii7 by add+ at ! end !  
foll[+ new subp>agraphs3  7,d7          
,conv]sion to ! l[-rat$ facility program
  7i7 ,9 g5]al ,on ! same date t !      
,secret>y implem5ts ! high-rat$ facility
 program "u p>agraph 7#ab71 ! ,secret>y 
%all conv]t ! special focus facility    
program "u ?is subsection to ! l[-rat$  
facility program4  7ii7 ,regulations ,! 
,secret>y %all c>ry out ! conv]sion "u  
clause 7i7 ?r\gh notice & comm5t        
rulemak+4  7iii7 ,additional requirem5ts
 = ! l[-rat$ facility program ,9        
addition to ! provisions t apply to !   

l[-rat$ facility program ?r\gh !        
conv]sion f ! special focus facility    
program1 ! succe$+ provisions ( ?is     
subsection %all also apply to ! l[-rat$ 
facility program4  7,e7 ,p>ticipation   
,subject to ! m9imum p>ticipation       
requirem5t "u subp>agraph 7,c71 !       
,secret>y %all designate ! l[e/ rat$    
nurs+ facilities "u ! rank+s "u p>agraph
 7#aa77;,b7 = p>ticipation 9 ! l[-rat$  
facility program4  7,f7 ,progressive    
en=cem5t actions ,! ,secret>y1 9        
consultation ) ,/ates1 %all utilize     
progressive en=cem5t actions1 ( increas+
 sev]ity1 to ensure facilities          
p>ticipat+ 9 ! l[-rat$ facility program 
meet ! applicable requirem5ts "u ?is    
,act4  7,g7 ,en=cem5t = patt]ns (       
defici5cy ,! ,secret>y may utilize      
en=cem5t actions specifi$ 9 subsection  
7h77#b7 to rem$y patt]ns ( defici5cies  
cit$ across multiple surveys4  7,h7     
,compliance assi/ance programs  7i7     
,on-site consultation & educational     
programm+  7,i7 ,9 g5]al ,! ,secret>y   

%all e/abli% on-site consultation &     
educational programm+ = nurs+ facilities
 p>ticipat+ 9 ! l[-rat$ facility program
 ) respect to compliance ) ! applicable 
requirem5ts "u ?is ,act4  7,,ii7 ,entity
 ,! on-site consultation & educational  
programm+ describ$ 9 subclause 7,i7 %all
 be c>ri$ out by quality improvem5t     
organizations "u "p ,b ( title ,,xi or  
o!r indep5d5t organizations ( a simil>  
type t d n h conflicts ( int]e/ & are   
deem$ appropriate by ! ,secret>y4       
7,,iii7 ,requir$ p>ticipation ,a nurs+  
facility p>ticipat+ 9 ! l[-rat$ facility
 program %all p>ticipate 9 any          
consultations & educational programm+   
describ$ 9 subclause 7,i7 conduct$ at ! 
facility4  7ii7 ,consultation indep5d5t 
( en=cem5t  7,i7 ,9 g5]al ,subject to   
subclause 7,,ii71 on-site consultations 
& educational programm+ describ$ 9      
clause 7i7 %all be conduct$ indep5d5tly 
( any en=cem5t activity4  7,,ii7        
,exception ,subclause 7,i7 %all n apply 
9 ! case :]e a trigg]+ ev5t at ! nurs+  

facility is obs]v$ 9 ! c\rse ( provid+  
on-site consultations & educational     
programm+ describ$ 9 clause 7i74 ,9     
e/abli%+ su* on-site consultations &    
educational programm+1 ! ,secret>y %all 
det]m9e ! trigg]+ ev5ts = :i* ! use (   
necess>y en=cem5t actions is p]mitt$    
not)/&+ ! limitation "u subclause 7,i74 
,su* trigg]+ ev5ts %all include ev5ts t 
are requir$ to be report$ "u ,/ate &    
,f$]al law & a patt]n ( defici5cies or  
problems t ! quality improvem5t         
organization or o!r organization has    
id5tifi$ = correction b :i* are         
consi/5tly n correct$4  7,i7 ,public    
availability  7i7 ,9 g5]al ,! ,secret>y 
%all ensure t a nurs+ facility's        
p>ticipation 9 ! l[-rat$ facility       
program is publicly ann\nc$1 includ+    
to-- 7,i7 resid5t family c\ncils2       
7,,ii7 resid5t att5d+ physicians2       
7,,iii7 ! ,/ate bo>d responsible = !    
lic5s+ ( ! nurs+ facility adm9i/rator at
 ! facility2  7,,iv7 ,/ate ,long-,t]m   
,c>e ,ombudsman programs 7z describ$ 9  

section #gab7;a77#a7 ( ! ,old] ,am]icans
 ,act ( #aife72 &  7,v7 ! community at  
l>ge4  7ii7 ,writt5 notification ,!     
,secret>y %all ensure t1 9 ! case ( a   
nurs+ facility t is p>ticipat+ 9 !      
l[-rat$ facility program1 resid5ts ( su*
 facility & family or legal             
repres5tatives are furni%$ )            
individualiz$ writt5 notice ( su*       
p>ticipation4 ,su* notice %all be       
provid$ to curr5t resid5ts & to new     
resid5ts prior to admission4  7,j7      
,requirem5t = removal ,! ,secret>y %all 
require t a nurs+ facility %[ improvem5t
 prior to removal f ! l[-rat$ facility  
program4  4  7,c7 ,use ( civil money    
p5alties ,section                       
#aiai7;h77#c77;,c77ii77,,iv77ff7 ( !    
,social ,security ,act 7#db ,u4,s4,c4   
#acifr7h77#c77;,c77ii77,,iv77ff77 is    
am5d$-- 7i7 by /rik+ & facility         
improvem5t initiatives & ins]t+ facility
 improvem5t initiatives2 &  7ii7 by     
ins]t+ ! foll[+ be=e ! p]iod at ! end3 1
 &1 on & aft] ! date ! ,secret>y makes !

 conv]sion describ$ 9 subsection        
7f77#aj77;,d71 consultation1 education1 
& o!r activities to fo/] improvem5t &   
rem$y root causes contribut+ to         
defici5cies cit$ across multiple surveys
 among facilities 9 ! l[-rat$ facility  
program "u subsection 7f77#aj74  7#c7   
,in=mation on high-rat$ & l[-rat$       
facilities on ,nurs+ ,home ,comp>e      
,m$ic>e website ,section #aiai7;i77#a7 (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #acifr7i77#a77 is am5d$-- 7,a7 9       
subp>agraph 7,a71 by add+ at ! end !    
foll[+ new clause3  7vi7 ,on & aft] !   
date ! ,secret>y implem5ts ! high-rat$  
facility program "u subsection 7f77#ab7 
& makes ! conv]sion "u subsection       
7f77#aj77;,d71 consi/5t ) subp>agraph   
7,c7-- 7,i7 = ea* nurs+ facility t is   
designat$ z a high-rat$ nurs+ facility  
"u subsection 7f77#ab71 ! date !        
facility 0 s designat$2 &  7,,ii7 = ea* 
nurs+ facility p>ticipat+ 9 ! l[-rat$   
facility program "u subsection 7f77#aj71
 ! date ! facility 0 id5tifi$ =         

inclusion 9 su* program4  2 &  7,b7 by  
add+ at ! end ! foll[+ new subp>agraphs3
  7,c7 ,di/9ctions = high-rat$ & l[-rat$
 facilities ,on & aft] ! date !         
,secret>y implem5ts ! high-rat$ facility
 program "u subsection 7f77#ab7 & makes 
! conv]sion "u subsection 7f77#aj77;,d71
 ! ,secret>y %all ensure t graphics1    
includ+ an appropriate explanation ( su*
 graphics1 are prom95tly display$ on !  
website describ$ 9 subp>agraph 7,a7 9   
ord] to di/+ui% ea* ( ! foll[+3 7i7     
,nurs+ facilities t are designat$ z     
high-rat$ nurs+ facilities "u subsection
 7f77#ab74  7ii7 ,nurs+ facilities t are
 p>ticipat+ 9 ! l[-rat$ facility program
 "u subsection 7f77#aj71 ) in=mation on 
facilities t h be5 plac$ 9 su* program m
 ?an "o "t ov] ! c\rse ( ! la/ #aj ye>s 
7includ+ ! numb] ( times su* nurs+      
facilities h be5 plac$ 9 ! program74    
7,d7 ,focus gr\ps & consum] te/+ ,9 ord]
 to help limit confusion1 p>ticul>ly    
among old] adults1 individuals )        
disabilities1 & family c>egiv]s1 !      

,secret>y %all utilize focus gr\ps & o!r
 consum] te/+ me?ods prior to includ+ ! 
additional in=mation "u subp>agraph     
7,a77vi7 & implem5t+ ! di/9ctions "u    
subp>agraph 7,c74  4  7d7 ,,gao /udy &  
report  7#a7 ,/udy ,! ,comptroll] ,g5]al
 ( ! ,unit$ ,/ates 79 ?is section ref]r$
 to z ! ,comptroll] ,g5]al7 %all conduct
 a /udy on ! quality ( items & s]vices  
furni%$ by skill$ nurs+ facilities "u   
title ,,xviii ( ! ,social ,security ,act
 & nurs+ facilities "u title ,,xix ( su*
 ,act1 & su* facilities' compliance ) ! 
applicable requirem5ts "u su* titles4   
,su* /udy %all include analysis ( !     
foll[+3 7,a7 ,! effectiv5ess ( ! l[-rat$
 facility program e/abli%$ "u p>agraph  
7#h7 ( section #ahai7;f7 ( ! ,social    
,security ,act 7#db ,u4,s4,c4           
#acie;i-#c7;f771 z am5d$ by subsection  
7b77#b71 & "u p>agraph 7#aj7 ( section  
#aiai7;f7 ( su* ,act 7#db ,u4,s4,c4     
#acifr7f771 z am5d$ by subsection       
7c77#b74  7,b7 ,o!r areas det]m9$       
appropriate by ! ,comptroll] ,g5]al4    

7#b7 ,report ,n lat] ?an #f ye>s aft] ! 
date ( enactm5t ( ?is ,act1 !           
,comptroll] ,g5]al %all submit to !     
appropriate ,committees ( ,congress a   
report conta9+ ! results ( ! /udy       
conduct$ "u p>agraph 7#a71 toge!r )     
recomm5dations = su* legislation &      
adm9i/rative action z ! ,comptroll]     
,g5]al det]m9es appropriate4  7e7 ,rules
 ( con/ruction  7#a7 ,surveys ,no?+ 9 ! 
provisions (1 or ! am5dm5ts made by1 ?is
 section %all be con/ru$ to all[ !      
,secret>y to modify or deviate f-- 7,a7 
a survey s*$ule t requires unann\nc$ &  
unanticipat$ survey+ ( skill$ nurs+     
facilities "u subsection 7g77#b77;,a77i7
 ( section #ahai ( ! ,social ,security  
,act 7#db ,u4,s4,c4 #acie;i-#c7;g77 or  
"u subsection 7g77#b77;,a77i7 ( section 
#aiai ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #acifr7g772  7,b7 ! survey+   
frequ5cy specifi$ "u subsection         
7g77#b77;,a77iii7 ( su* section #ahai or
 "u subsection 7g77#b77;,a77iii7 ( su*  
section #aiai2 or  7,c7 surveys &       

inve/igations z requir$ "u subsection   
7g77#d7 ( su* section #ahai or "u       
subsection 7g77#d7 ( su* section #aiai4 
7#b7 ,acc\ntability & ,/ate law ,no?+ 9 
! provisions (1 or ! am5dm5ts made by1  
?is section %all be con/ru$ to impact ! 
ability ( a resid5t1 ! family ( a       
resid5t1 or a successor 9 int]e/ to hold
 a skill$ nurs+ facility or nurs+       
facility acc\ntable or *ange protections
 grant$ "u ,/ate law4  #c4 ,def9itions  
,9 ?is ,act3 7#a7 ,appropriate          
,committees ( ,congress ,! t]m          
appropriate ,committee ( ,congress      
means-- 7,a7 ! ,committee on ,f9ance ( !
 ,s5ate2  7,b7 ! ,committee on ,heal?1  
,education1 ,labor1 & ,p5sions ( !      
,s5ate2  7,c7 ! ,special ,committee on  
,ag+ ( ! ,s5ate2  7,d7 ! ,committee on  
,ways & ,means ( ! ,h\se (              
,repres5tatives2 &  7,e7 ! ,committee on
 ,en]gy & ,comm]ce ( ! ,h\se (          
,repres5tatives4  7#b7 ,nurs+ facility  
,! t]m nurs+ facility has ! mean+ giv5 t
 t]m 9 section #aiai7;a7 ( ! ,social    

,security ,act 7#db ,u4,s4,c4           
#acifr7a774  7#c7 ,skill$ nurs+ facility
 ,! t]m skill$ nurs+ facility has !     
mean+ giv5 t t]m 9 section #ahai7;a7 ( !
 ,social ,security ,act 7#db ,u4,s4,c4  
#acie;i-#c7;a774  7#d7 ,secret>y ,! t]m 
,secret>y means ! ,secret>y ( ,heal? &  
,human ,s]vices4