,i  #aag? ,,congress  #a/ ,session  ,h4 
,r4 #eafi  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,septemb] #c1         
#bjba,mr4 ,neal 7= himself & ,mr4       
,pallone7 introduc$ ! foll[+ bill2 :i* 0
 ref]r$ to ! ,committee on ,ways &      
,means1 & 9 addition to ! ,committee on 
,en]gy & ,comm]ce1 = a p]iod to be      
subsequ5tly det]m9$ by ! ,speak]1 9 ea* 
case = consid]ation ( su* provisions z  
fall )9 ! jurisdiction ( ! committee    
conc]n$  ,a ,,bill  ,to improve c>e     
furni%$ & to support ! work=ce 9 skill$ 
nurs+ facilities "u ! ,m$ic>e program & 
9 nurs+ facilities "u ! ,m$icaid        
program1 & = o!r purposes4  #a4 ,%ort   
title ,?is ,act may be cit$ z ! ,nurs+  
,home ,improvem5t & ,acc\ntability ,act 
( #bjba4  ,i ,transp>5cy & acc\ntability
  #aja4 ,improv+ ! accuracy &           
reliability ( c]ta9 skill$ nurs+        
facility data  7a7 ,r$uction 9 paym5ts =
 inaccurate report+ ,section            
#ahhh7;e77#f77;,a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    

#acieyy7e77#f77;,a77 is am5d$-- 7#a7 9 !
 head]1 by /rik+ = failure to report2 & 
7#b7 9 clause 7i7-- 7,a7 by /rik+ ,=    
fiscal ye>s & ins]t+ ! foll[+3  7,i7    
,failure to report ,= fiscal ye>s  2 &  
7,b7 by add+ at ! end ! foll[+ new      
subclause3  7,,ii7 ,report+ ( inaccurate
 in=mation ,= fiscal ye>s beg9n+ )      
fiscal ye> #bjbe1 9 ! case ( a skill$   
nurs+ facility t submits data "u ?is    
p>agraph1 measures "u subsection 7h71 or
 resid5t assessm5t data describ$ 9      
section #ahai7;b77#c7 ) respect to su*  
fiscal ye> t is inaccurate 7z det]m9$ by
 ! ,secret>y ?r\gh ! validation process 
describ$ 9 section #ahhh7;h77#ab7 or    
o!rwise71 aft] det]m9+ ! p]c5tage       
describ$ 9 p>agraph 7#e77;,b77i71 & aft]
 application ( clauses 7ii7 & 7iii7 (   
p>agraph 7#e77;,b7 & ( subclause 7,i7 if
 ?is clause 7if applicable71 ! ,secret>y
 %all r$uce su* p]c5tage = paym5t rates 
dur+ su* fiscal ye> by #b p]c5tage      
po9ts4  4  7b7 ,data & measures         
validation ,section #ahhh7;h77#ab7 ( !  

,social ,security ,act 7#db ,u4,s4,c4   
#acieyy7h77#ab77 is am5d$-- 7#a7 9      
subp>agraph 7,a71 by /rik+ & ! data     
submitt$ "u subsection 7e77#f7 & ins]t+ 
1 ! data submitt$ "u subsection 7e77#f71
 &1 beg9n+ ) fiscal ye> #bjbd1 ! resid5t
 assessm5t data describ$ 9 section      
#ahai7;b77#c72  7#b7 9 subp>agraph 7,b71
 by /rik+ ( #e1jjj1jjj & all t foll[s   
?r\gh ! p]iod at ! end & ins]t+ !       
foll[+3 (-- 7i7 #e1jjj1jjj = ea* (      
fiscal ye>s #bjbc ?r\gh #bjbe2 &  7ii7  
#ej1jjj1jjj = ! p]iod ( fiscal ye>s     
#bjbf ?r\gh #bjce2 to ! ,c5t]s = ,m$ic>e
  ,m$icaid ,s]vices ,program ,managem5t 
,acc\nt1 to rema9 available until       
exp5d$4 4  7c7 ,provid+ au?ority ,to    
collect data on additional measures     
,section #ahhh7;e77#f77;,b77i77,,ii7 ( !
 ,social ,security ,act 7#db ,u4,s4,c4  
#acieyy7e77#f77;,b77i77,,ii77 is am5d$  
by ins]t+ 1 & data on any o!r validat$  
measure specifi$ by ! ,secret>y aft] "u 
su* subsection 7d77#a74  #ajb4 ,ensur+  
accurate in=mation on co/ reports       

,section #ahhh7;f7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acieyy7f77 is     
am5d$ by add+ at ! end ! foll[+ new     
p>agraphs3  7#e7 ,audit ( co/ reports   
7,a7 ,9 g5]al ,beg9n+ 9 #bjbb1 &        
annually !reaft]1 ! ,secret>y %all      
conduct an audit ( co/ reports submitt$ 
"u ?is title = a repres5tative sample ( 
skill$ nurs+ facilities4  7,b7 ,fund+ ,!
 ,secret>y %all provide = ! transf]1 f !
 ,f$]al ,hospital ,insurance ,tru/ ,fund
 "u section #ahag to ! ,c5t]s = ,m$ic>e 
,m$icaid ,s]vices ,program ,managem5t   
,acc\nt1 ( #bej1jjj1jjj = fiscal ye>    
#bjbc = purposes ( c>ry+ out ?is        
p>agraph4 ,am\nts transf]r$ pursuant to 
! previ\s s5t5ce %all rema9 available   
until exp5d$4  7#f7 ,review (           
relation%ip betwe5 co/ report data &    
quality  7,a7 ,9 g5]al ,n lat] ?an #b   
ye>s aft] ! ,secret>y completes ! fir/  
audit describ$ 9 p>agraph 7#e71 & n less
 frequ5tly ?an once e #b ye>s !reaft]1 !
 ,inspector ,g5]al ( ! ,dep>tm5t (      
,heal? & ,human ,s]vices %all conduct an

 analysis (1 & submit to ,congress a    
report on1 ! relation%ip betwe5 skill$  
nurs+ facility exp5ditures = functional 
acc\nts describ$ 9 p>agraph 7#c7 &      
skill$ nurs+ facility quality 7z        
specifi$ by ! ,inspector ,g5]al74  7,b7 
,fund+ ,! ,secret>y %all provide = !    
transf]1 f ! ,f$]al ,hospital ,insurance
 ,tru/ ,fund "u section #ahag to !      
,inspector ,g5]al ( ! ,dep>tm5t ( ,heal?
 & ,human ,s]vices #be1jjj1jjj = fiscal 
ye> #bjbc = purposes ( c>ry+ out ?is    
p>agraph4 ,am\nts transf]r$ pursuant to 
! previ\s s5t5ce %all rema9 available   
until exp5d$4  4  #ajc4 ,requir+ a      
surety bond = skill$ nurs+ facilities   
7a7 ,m$ic>e ,section #ahai7;a7 ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#acie;i-#c7;a77 is am5d$-- 7#a7 9       
p>agraph 7#b71 by /rik+ & at ! end2     
7#b7 9 p>agraph 7#c71 by /rik+ ! p]iod &
 ins]t+ 2 &2 &  7#c7 by add+ at ! end ! 
foll[+ new p>agraph3  7#d7 provides !   
,secret>y ) a surety bond 9 a =m        
specifi$ by ! ,secret>y & 9 an am\nt t  

is n less ?an ! m9imum ( #ejj1jjj1      
unless ! ,secret>y waives ! provision ( 
su* surety bond due to su* facility     
provid+ a comp>able surety bond "u ,/ate
 law4  4  7b7 ,m$icaid ,section         
#aiai7;a7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #acifr7a77 is am5d$--    
7#a7 9 p>agraph 7#b71 by /rik+ & at !   
end2  7#b7 9 p>agraph 7#c71 by /rik+ !  
p]iod & ins]t+ 2 &2 &  7#c7 by ins]t+   
aft] p>agraph 7#c7 ! foll[+ new         
p>agraph3  7#d7 provides ! ,secret>y ) a
 surety bond 9 a =m specifi$ by !       
,secret>y & 9 an am\nt t is n less ?an !
 m9imum ( #ejj1jjj1 unless ! ,secret>y  
waives ! provision ( su* surety bond due
 to su* facility provid+ a comp>able    
surety bond "u ,/ate law4  4  #ajd4     
,survey improvem5ts  7a7 ,9 g5]al       
,section #aabh;,i ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #acbj;a-#g;j7 is    
am5d$-- 7#a7 9 ! section head+1 by /rik+
 ,acc\ntability requirem5ts = & ins]t+  
,additional requirem5ts ) respect to2 & 
7#b7 by add+ at ! end ! foll[+ new      

subsection3  7i7 ,survey improvem5ts    
7#a7 ,review ,! ,secret>y %all review   
7&1 z appropriate1 id5tify plans to     
improve7 ! foll[+3 7,a7 ,! ext5t to :i* 
surveys conduct$ "u subsection 7g7 (    
sections #ahai & #aiai & ! en=cem5t     
process "u subsection 7h7 ( sections    
#ahai & #aiai result 9 increas$         
compliance ) requirem5ts "u sections    
#ahai & #aiai & subp>t ,b ( "p #dhc (   
title #db1 ,code ( ,f$]al ,regulations1 
) respect to facilities4  7,b7 ,!       
timel9ess & ?or\ghness ( ,/ate ag5cy    
v]ification ( defici5cy corrections at  
facilities4  7,c7 ,! appropriat5ess ( ! 
scop+ & sub/antiation ( cit$ defici5cies
 at facilities4  7,d7 ,! accuracy ( !   
id5tification & appropriat5ess ( ! scop+
 ( life safety1 infection control1 &    
em]g5cy prep>$ness defici5cies at       
facilities4  7,e7 ,! timel9ess ( ,/ate  
ag5cy inve/igations (-- 7i7 compla9ts at
 facilities2 &  7ii7 report$ allegations
 ( abuse1 neglect1 & exploitation at    
facilities4  7,f7 ,! consi/5cy (        

facility report+ ( sub/antiat$ compla9ts
 to law en=cem5t4  7,g7 ,! ability ( !  
,/ate ag5cy to suffici5tly hire1 tra91 &
 reta9 individuals :o conduct surveys4  
7,h7 ,any o!r area relat$ to surveys (  
facilities1 or ! individuals conduct+   
su* surveys1 det]m9$ appropriate by !   
,secret>y4  7#b7 ,report ,n lat] ?an #c 
ye>s aft] ! date ( enactm5t ( ?is       
subsection1 ! ,secret>y %all submit to  
,congress a report on ! review conduct$ 
"u p>agraph 7#a71 toge!r )              
recomm5dations = su* legislation &      
adm9i/rative action z ! ,secret>y       
det]m9es to be appropriate4  7#c7       
,support ,if det]m9$ appropriate by !   
,secret>y1 bas$ on ! review "u p>agraph 
7#a71 ! ,secret>y %all provide tra9+1   
tools1 te*nical assi/ance1 & f9ancial   
support to ,/ate ag5cies t p]=m surveys 
( facilities = ! purpose ( improv+ !    
surveys conduct$ "u subsection 7g7 & !  
en=cem5t process "u subsection 7h7 )    
respect to ! areas review$ "u p>agraph  
7#a74  7#d7 ,fund+ ,!re is appropriat$  

to ! ,secret>y1 out ( any monies 9 !    
,treasury n o!rwise appropriat$1        
#egj1jjj1jjj1 to rema9 available until  
exp5d$1 = purposes ( c>ry+ out ?is      
subsection4  4  #aje4 ,prohibit+        
pre-dispute arbitration agreem5ts  7a7  
,m$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 ent] into a 
pre-dispute arbitration agreem5t ) an   
individual apply+ to reside or resid+ 9 
! facility 7or a legal repres5tative (  
su* resid5t71 & may n ent] into an      
agreem5t = s]vices ) an entity or       
individual t ent]s into a pre-dispute   
arbitration agreem5t ) an individual    
apply+ to reside or resid+ 9 ! facility 
7or a legal repres5tative ( su*         
resid5t74  7,b7 ,no validity or en=cem5t
 ,a skill$ nurs+ facility %all n en=ce a
 pre-dispute arbitration agreem5t aga9/ 

a resid5t or =m] resid5t ( a skill$     
nurs+ facility 7or a legal repres5tative
 ( su* resid5t71 )\t reg>d to :e!r !    
agreem5t 0 made prior to or aft] !      
effective date ( ?is p>agraph4  7,c7    
,def9ition ( pre-dispute arbitration    
agreem5t ,9 ?is p>agraph1 ! t]m         
pre-dispute arbitration agreem5t means  
any agreem5t to arbitrate a pot5tial    
dispute t1 z ( ! date on :i* su*        
agreem5t is ent]$ into1 has n yet aris54
  7,d7 ,judicial review ,a det]m9ation z
 to :e!r & h[ ?is p>agraph applies to a 
pre-dispute 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 may 
n ent] into a pre-dispute arbitration   
agreem5t ) an individual receiv+ su*    
s]vices 7or a legal repres5tative ( su* 
individual74 ,a provid] ( su* s]vices 7&
 any employee1 ag5t1 relat$ entity1 or  
affiliate ( su* provid]7 %all n en=ce a 
pre-dispute arbitration agreem5t aga9/  
an individual receiv+ su* s]vices1 or :o
 =m]ly receiv$ su* s]vices 7or a legal  
repres5tative ( su* individual71 )\t    
reg>d to :e!r su* agreem5t 0 made prior 
to ! effective date ( ?is subsection4   
7#b7 ,def9ition ( pre-dispute           
arbitration agreem5t ,9 ?is subsection1 

! t]m pre-dispute arbitration agreem5t  
means any agreem5t to arbitrate a       
pot5tial dispute t1 z ( ! date on :i*   
su* agreem5t is ent]$ into1 has n yet   
aris54  7#c7 ,judicial review ,a        
det]m9ation z to :e!r & h[ ?is          
subsection applies to a pre-dispute     
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 ent] into a pre-dispute  
arbitration agreem5t ) an individual    
apply+ to reside or resid+ 9 ! facility 
7or a legal repres5tative ( su*         
resid5t71 & may n ent] into an agreem5t 

= s]vices ) an entity or individual t   
ent]s into a pre-dispute arbitration    
agreem5t ) an individual apply+ to      
reside or resid+ 9 ! facility 7or a     
legal repres5tative ( su* resid5t74     
7,b7 ,no validity or en=cem5t ,a nurs+  
facility %all n en=ce a pre-dispute     
arbitration agreem5t aga9/ a resid5t or 
=m] resid5t ( a nurs+ facility 7or a    
legal repres5tative ( su* resid5t71 )\t 
reg>d to :e!r ! agreem5t 0 made prior to
 or aft] ! effective date ( ?is         
p>agraph4  7,c7 ,def9ition ( pre-dispute
 arbitration agreem5t ,9 ?is p>agraph1 !
 t]m pre-dispute arbitration agreem5t   
means any agreem5t to arbitrate a       
pot5tial dispute t1 z ( ! date on :i*   
su* agreem5t is ent]$ into1 has n yet   
aris54  7,d7 ,judicial review ,a        
det]m9ation z to :e!r & h[ ?is p>agraph 
applies to a pre-dispute 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  #ajf4 ,improvem5ts to !   
special focus facility program  7a7     
,appropriate p>ticipation  7#a7 ,m$ic>e 
,section #ahai7;f77#h7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acie;i-#c7;f77#h77 is am5d$-- 7,a7 9   
subp>agraph 7,a71 by /rik+ ,! ,secret>y 
& ins]t+ ,subject to ! succe$+          
provisions ( ?is subsection1 !          
,secret>y2 &  7,b7 by add+ at ! end !   
foll[+ new subp>agraph3  7,c7           
,appropriate p>ticipation ,n lat] ?an   
,octob] #a1 #bjbb1 ! ,secret>y %all     
ensure t ! numb] ( facilities p>ticipat+
 9 ! special focus facility program is n
 less ?an #e p]c5t ( all skill$ nurs+   
facilities4  4  7#b7 ,m$icaid ,section  
#aiai7;f77#aj7 ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acier7f77#aj77 is  
am5d$-- 7,a7 9 subp>agraph 7,a71 by     
/rik+ ,! ,secret>y & ins]t+ ,subject to 
! succe$+ provisions ( ?is subsection1 !
 ,secret>y2 &  7,b7 by add+ at ! end !  

foll[+ new subp>agraph3  7,c7           
,appropriate p>ticipation ,n lat] ?an   
,octob] #a1 #bjbb1 ! ,secret>y %all     
ensure t ! numb] ( facilities p>ticipat+
 9 ! special focus facility program is n
 less ?an #e p]c5t ( all nurs+          
facilities4  4  7b7 ,compliance         
assi/ance programs  7#a7 ,m$ic>e        
,section #ahai7;f77#h7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acie;i-#c7;f77#h771 z am5d$ by         
subsection 7a77#a71 is am5d$ by add+ at 
! end ! foll[+ new subp>agraph3  7,d7   
,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 ! special focus 
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 ! special focus   
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$4  4  7#b7
 ,m$icaid ,section #aiai7;f77#aj7 ( !   
,social ,security ,act 7#db ,u4,s4,c4   
#acier7f77#aj771 z am5d$ by subsection  
7a77#b71 is am5d$ by add+ at ! end !    
foll[+ new subsection3  7,d7 ,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 ! special focus 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 ! special focus   
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$4  4  7c7 ,fund+ = 
! special focus facility program1       
includ+ compliance assi/ance programs   
,section #ahai7;f77#h7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acie;i-#c7;f77#h771 z am5d$ by         
subsections 7a77#a7 & 7b77#a71 is am5d$ 
by add+ at ! end ! foll[+ new           
subp>agraph3  7,e7 ,= purposes ( c>ry+  
out ?is p>agraph & section              
#aiai7;f77#aj71 !re is appropriat$ to ! 
,secret>y1 out ( any monies 9 !         
,treasury n o!rwise appropriat$1        
#ad1hjj1jjj = fiscal ye> #bjbb & ea*    
subsequ5t fiscal ye>1 to rema9 available
 until exp5d$4  4  ,,ii ,/aff+          
,improvem5ts  #bja4 ,nurse /aff+        
requirem5ts  7a7 ,9 g5]al ,title ,,xi ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#acja et seq47 is am5d$ by ins]t+ aft]  
section #aabh,k ! foll[+ new section3   

#aabh,l4 ,nurse /aff+ requirem5ts =     
facilities  7a7 ,/udy ,n lat] ?an #c    
ye>s aft] ! date ( ! enactm5t ( ?is     
section1 & n less frequ5tly ?an once e  
#e ye>s !reaft]1 ! ,secret>y %all       
conduct a /udy & submit to ,congress a  
report on ! appropriat5ess ( e/abli%+   
m9imum /aff to resid5t ratios = nurs+   
/aff = skill$ nurs+ facilities 7z def9$ 
9 section #ahai7;a77 & nurs+ facilities 
7z def9$ 9 section #aiai7;a774 ,ea* su* 
report %all include-- 7#a7 ) respect to 
! fir/ su* report1 recomm5dations reg>d+
 appropriate m9imum ratios ( regi/]$    
nurses 7&1 if practicable1 lic5s$       
practical nurses 7or lic5s$ vocational  
nurses7 & c]tifi$ nurs+ assi/ants7 to   
resid5ts at su* skill$ nurs+ facilities 
& su* nurs+ facilities2 &  7#b7 )       
respect to ea* subsequ5t su* report1    
recomm5dations reg>d+ appropriate m9imum
 ratios ( regi/]$ nurses1 lic5s$        
practical nurses 7or lic5s$ vocational  
nurses71 & c]tifi$ nurs+ assi/ants to   
resid5ts at su* skill$ nurs+ facilities 

& su* nurs+ facilities4  7b7            
,promulgation ( regulations  7#a7 ,9    
g5]al ,n lat] ?an #b ye>s aft] !        
,secret>y fir/ submits a report "u      
subsection 7a71 ! ,secret>y %all-- 7,a7 
specify ?r\gh regulations1 consi/5t )   
su* report1 appropriate m9imum ratios   
7if any7 ( regi/]$ nurses 7&1 if        
practicable1 lic5s$ practical nurses 7or
 lic5s$ vocational nurses7 & c]tifi$    
nurs+ assi/ants7 to resid5ts at skill$  
nurs+ facilities & nurs+ facilities2 &  
7,b7 subject to any waiv] 9 effect "u   
section #ahai7;b77#i77;,b7 or           
#aiai7;b77#i77;,b71 require su* skill$  
nurs+ facilities & su* nurs+ facilities 
to comply ) su* ratios4  7#b7 ,update ,n
 lat] ?an #b ye>s aft] ! submission (   
ea* subsequ5t report "u subsection 7a71 
! ,secret>y %all1 consi/5t ) su* report1
 update ! regulations describ$ 9        
p>agraph 7#a77;,a7 to reflect           
appropriate m9imum ratios 7if any7 (    
regi/]$ nurses1 lic5s$ practical nurses 
7or lic5s$ vocational nurses71 & c]tifi$

 nurs+ assi/ants to resid5ts at skill$  
nurs+ facilities & nurs+ facilities4    
7c7 ,fund+ ,! ,secret>y %all provide = !
 transf]1 f ! ,f$]al ,hospital          
,insurance ,tru/ ,fund "u section #ahag 
to ! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices
 ,program ,managem5t ,acc\nt1 (         
#ej1jjj1jjj = fiscal ye> #bjbb =        
purposes ( c>ry+ out ?is section4       
,am\nts transf]r$ pursuant to ! previ\s 
s5t5ce %all rema9 available until       
exp5d$4  4  7b7 ,imposition (           
requirem5ts  7#a7 ,m$ic>e ,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 ,nurse /aff+ requirem5t  7,a7 ,9   
g5]al ,subject to subp>agraph 7,b71 a   
skill$ nurs+ facility %all comply ) any 
m9imum /aff+ ratios = regi/]$ nurses1   
lic5s$ practical nurses 7or lic5s$      
vocational nurses71 or c]tifi$ nurse    
assi/ants specifi$ by ! ,secret>y = su* 
a facility 9 regulations promulgat$ "u  
section #aabh,l7b7 or1 if great]1 z     

specifi$ by ! ,/ate involv$ = su* a     
facility4  7,b7 ,waiv]  7i7 ,9 g5]al ,! 
,secret>y may waive ! application (     
subp>agraph 7,a7 ) respect to a skill$  
nurs+ facility if ! ,secret>y f9ds t--  
7,i7 ! facility is locat$ 9 a rural area
 & ! supply ( skill$ nurs+ facility     
s]vices 9 su* area is n suffici5t to    
meet ! ne$s ( individuals resid+ !re92  
7,,ii7 ! ,secret>y provides notice ( !  
waiv] to ! ,/ate long-t]m c>e ombudsman 
7e/abli%$ "u section #cjg7;a77#ab7 ( !  
,old] ,am]icans ,act ( #aife7 & !       
protection & advocacy sy/em 9 ! ,/ate = 
! m5tally ill & ! m5tally ret>d$2 &     
7,,iii7 ! facility t is grant$ su* a    
waiv] notifies resid5ts ( ! facility    
7or1 :]e appropriate1 ! gu>dians or     
legal repres5tatives ( su* resid5ts7 &  
memb]s ( _! imm$iate families ( ! waiv]4
  7ii7 ,r5ewal ,any waiv] 9 effect "u   
?is subp>agraph %all be subject to      
annual r5ewal4  4  7#b7 ,m$icaid        
,section #aiai7;b7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acifr7b77 is am5d$

 by add+ at ! end ! foll[+ new p>agraph3
  7#i7 ,nurse /aff+ requirem5t  7,a7 ,9 
g5]al ,subject to subp>agraph 7,b71 a   
nurs+ facility %all comply ) any m9imum 
/aff+ ratios = regi/]$ nurses1 lic5s$   
practical nurses 7or lic5s$ vocational  
nurses71 or c]tifi$ nurse assi/ants     
specifi$ by ! ,secret>y = su* a facility
 9 regulations promulgat$ "u section    
#aabh,l7b7 or1 if great]1 z specifi$ by 
! ,/ate involv$ = su* a facility4  7,b7 
,waiv]  7i7 ,9 g5]al ,! ,secret>y may   
waive ! application ( subp>agraph 7,a7 )
 respect to a nurs+ facility if !       
,secret>y f9ds t-- 7,i7 ! facility is   
locat$ 9 a rural area & ! supply ( nurs+
 facility s]vices 9 su* area is n       
suffici5t to meet ! ne$s ( individuals  
resid+ !re92  7,,ii7 ! ,secret>y        
provides notice ( ! waiv] to ! ,/ate    
long-t]m c>e ombudsman 7e/abli%$ "u     
section #cjg7;a77#ab7 ( ! ,old]         
,am]icans ,act ( #aife7 & ! protection &
 advocacy sy/em 9 ! ,/ate = ! m5tally   
ill & ! m5tally ret>d$2 &  7,,iii7 !    

facility t is grant$ su* a waiv]        
notifies resid5ts ( ! facility 7or1 :]e 
appropriate1 ! gu>dians or legal        
repres5tatives ( su* resid5ts7 & memb]s 
( _! imm$iate families ( ! waiv]4  7ii7 
,r5ewal ,any waiv] 9 effect "u ?is      
subp>agraph %all be subject to annual   
r5ewal4  4  #bjb4 ,improv+ ,nurs+ ,home 
,comp>e /aff+ data  7a7 ,m$ic>e ,section
 #ahai7;i77#a77;,a77i7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acie;i-#c7;i77#a77;,a77i77 is am5d$ by 
ins]t+ 7exclud+1 ) respect to su* data  
provid$ on or aft] ,octob] #a1 #bjbb1   
any h\rs sp5t on adm9i/rative duties by 
lic5s$ nurse /aff7 &1 beg9n+ ,octob] #a1
 #bjbb1 data on ! h\rs ( c>e provid$ p] 
resid5t p] week5d day aft] p] resid5t p]
 day4  7b7 ,m$icaid ,section            
#aiai7;i77#a77;,a77i7 ( ! ,social       
,security ,act 7#db ,u4,s4,c4           
#acifr7i77#a77;,a77i77 is am5d$ by      
ins]t+ 7exclud+1 ) respect to su* data  
provid$ on or aft] ,octob] #a1 #bjbb1   
any h\rs sp5t on adm9i/rative duties by 

lic5s$ nurse /aff7 &1 beg9n+ ,octob] #a1
 #bjbb1 data on ! h\rs ( c>e provid$ p] 
resid5t p] week5d day aft] p] resid5t p]
 day4  #bjc4 ,ensur+ ! submission (     
accurate /aff+ data ,section #aabh;,i7g7
 ( ! ,social ,security ,act 7#db        
,u4,s4,c4 #acbj;a-#g;j7g77 is am5d$--   
7#a7 by r$esignat+ p>agraphs 7#a7 ?r\gh 
7#d7 z subp>agraphs 7,a7 ?r\gh 7,d71    
respectively1 & adju/+ ! m>g9s          
accord+ly2  7#b7 9 subp>agraph 7,d71 z s
 r$esignat$1 by /rik+ p>agraph 7#a7 &   
ins]t+ subp>agraph 7,a72  7#c7 by mov+ !
 flu% matt] foll[+ subp>agraph 7,d71 z s
 r$esignat$1 #b ems to ! "r2  7#d7 by   
/rik+ ,beg9n+ n lat] ?an & ins]t+ !     
foll[+3  7#a7 ,9 g5]al ,beg9n+ n lat]   
?an  2 &  7#e7 by add+ at ! end ! foll[+
 new p>agraph3  7#b7 ,p5alty =          
submission ( inaccurate in=mation ,any  
facility t submits inaccurate in=mation 
to ! ,secret>y "u p>agraph 7#a7 may be  
subject to a civil monet>y p5alty n to  
exce$ #aj1jjj = ea* su* submission4 ,!  
provisions ( section #aabh;,a 7o!r ?an  

subsections 7a7 & 7b7 ( su* section7    
%all apply to a civil money p5alty "u ! 
prec$+ s5t5ce 9 ! same mann] z su*      
provisions apply to a p5alty or proce$+ 
"u section #aabh;,a7a74  4  #bjd4       
,requir+ #bd-;h\r use ( regi/]$         
pr(essional nurses  7a7 ,m$ic>e ,section
 #ahai7;b77#d77;,c77i7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acie;i-#c7;b77#d77;,c77i77 is am5d$ by 
/rik+ regi/]$ pr(essional nurse & all t 
foll[s ?r\gh ! p]iod at ! end & ins]t+ !
 foll[+3 regi/]$ pr(essional nurse1 )   
respect to su* s]vices furni%$-- 7,i7   
be=e ,octob] #a1 #bjbc1 at lea/ #h      
consecutive h\rs a day1 #g days a week2 
&  7,,ii7 on or aft] su* date1 #bd h\rs 
a day1 #g days a week4  4  7b7 ,m$icaid 
,section #aiai7;b77#d77;,c77i77,,ii7 ( !
 ,social ,security ,act 7#db ,u4,s4,c4  
#acifr7b77#d77;,c77i77,,ii77 is am5d$ by
 /rik+ regi/]$ pr(essional nurse & all t
 foll[s ?r\gh ! p]iod at ! end & ins]t+ 
! foll[+3 regi/]$ pr(essional nurse1 )  
respect to su* s]vices furni%$-- 7aa7   

be=e ,octob] #a1 #bjbc1 at lea/ #h      
consecutive h\rs a day1 #g days a week2 
&  7bb7 on or aft] su* date1 #bd h\rs a 
day1 #g days a week4  4  #bje4          
,provision ( infection control s]vices  
7a7 ,m$ic>e ,section #ahai7;d77#c7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#acie;i-#c7;d77#c77 is am5d$-- 7#a7 by  
r$esignat+ subp>agraphs 7,a7 & 7,b7 z   
clauses 7i7 & 7ii7 respectively1 & mov+ 
su* clauses #b ems to ! "r2  7#b7 by    
/rik+ environm5t4--,a skill$ & ins]t+   
8environm5t4--  7,a7 ,9 g5]al ,a skill$ 
2  7#c7 9 subp>agraph 7,a71 z am5d$ by  
p>agraphs 7#a7 & 7#b7-- 7,a7 9 clause   
7i71 by /rik+ 1 & at ! end & ins]t+ a   
semicolon2  7,b7 9 clause 7ii71 by /rik+
 ! p]iod at ! end & ins]t+ 2 &2 &  7,c7 
by add+ at ! end ! foll[+ new clause3   
7iii7 provide1 directly or "u           
arrangem5ts ) o!rs1 = infection control 
s]vices ov]se5 by an infection          
prev5tioni/ = a m9imum numb] ( h\rs p]  
week z det]m9$ appropriate by !         
,secret>y 7b1 subject to subp>agraph    

7,b71 n less ?an #dj h\rs p] week74  2 &
  7#d7 by add+ at ! end ! foll[+ new    
subp>agraph3  7,b7 ,r$uction 9 requir$  
numb] ( h\rs = infection control s]vices
 ov]se5 by an infection prev5tioni/  7i7
 ,9 g5]al ,! ,secret>y may grant a waiv]
 to a skill$ nurs+ facility "u :i* !    
numb] ( h\rs p] week t infection control
 s]vices ov]se5 by an infection         
prev5tioni/ at ! facility are requir$ "u
 subp>agraph 7,a77iii7 are r$uc$ if !   
,secret>y f9ds t-- 7,i7 ! facility--    
7aa7 is locat$ 9 a rural area & ! supply
 ( skill$ nurs+ facility s]vices 9 su*  
area is n suffici5t to meet ! ne$s (    
individuals resid+ !re92 or  7bb7 is ( a
 size t necessitates a l[] requirem5t2  
7,,ii7 ! ,secret>y provides notice ( !  
waiv] to ! ,/ate ,long-,t]m ,c>e        
,ombudsman 7support$ "u title ,,iii or  
*apt] #b ( subtitle ,a ( title ,,vii ( !
 ,old] ,am]icans ,act ( #aife7 & !      
protection & advocacy sy/em 7z def9$ 9  
section #ajb ( ! ,developm5tal          
,disabilities ,assi/ance & ,bill (      

,rights ,act ( #bjjj7 9 ! ,/ate2 &      
7,,iii7 ! facility t is grant$ ! waiv]  
notifies resid5ts ( ! facility 7or1 :]e 
appropriate1 ! gu>dians or legal        
repres5tatives ( su* resid5ts7 & memb]s 
( _! imm$iate families ( ! waiv]4  7ii7 
,annual review ,a waiv] "u ?is          
subp>agraph %all be subject to annual   
review by ! ,secret>y4  4  7b7 ,m$icaid 
,section #aiai7;d77#c7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acifr7d77#c77 is am5d$-- 7#a7 by       
r$esignat+ subp>agraphs 7,a7 & 7,b7 z   
clauses 7i7 & 7ii7 respectively1 & mov+ 
su* clauses #b ems to ! "r2  7#b7 by    
/rik+ environm5t4--,a nurs+ facility &  
ins]t+ 8environm5t4--  7,a7 ,9 g5]al ,a 
nurs+ facility  2  7#c7 9 subp>agraph   
7,a71 z am5d$ by p>agraphs 7#a7 & 7#b7--
 7,a7 9 clause 7i71 by /rik+ 1 & at !   
end & ins]t+ a semicolon2  7,b7 9 clause
 7ii71 by /rik+ ! p]iod at ! end &      
ins]t+ 2 &2 &  7,c7 by add+ at ! end !  
foll[+ new clause3  7iii7 provide1      
directly or "u arrangem5ts ) o!rs1 =    

infection control s]vices ov]se5 by an  
infection prev5tioni/ = a m9imum numb] (
 h\rs p] week z det]m9$ appropriate by !
 ,secret>y 7b1 subject to subp>agraph   
7,b71 n less ?an #dj h\rs p] week74  2 &
  7#d7 by add+ at ! end ! foll[+ new    
subp>agraph3  7,b7 ,r$uction 9 requir$  
numb] ( h\rs = infection control s]vices
 ov]se5 by an infection prev5tioni/  7i7
 ,9 g5]al ,a ,/ate may grant a waiv] to 
a nurs+ facility "u :i* ! numb] ( h\rs  
p] week t infection control s]vices     
ov]se5 by an infection prev5tioni/ at ! 
facility are requir$ "u subp>agraph     
7,a77iii7 are r$uc$ if-- 7,i7 ! facility
 demon/rates to ! satisfaction ( ! ,/ate
 t ! facility has be5 unable1 despite   
dilig5t ef=ts 7includ+ (f]+ wages at !  
community prevail+ rate = nurs+         
facilities71 to recruit appropriate     
p]sonnel2  7,,ii7 ! ,/ate det]m9es t !  
waiv] w n endang] ! heal? or safety (   
individuals /ay+ 9 ! facility2  7,,iii7 
! ,/ate ag5cy grant+ ! waiv] provides   
notice ( ! waiv] to ! ,/ate ,long-,t]m  

,c>e ,ombudsman 7support$ "u title ,,iii
 or *apt] #b ( subtitle ,a ( title ,,vii
 ( ! ,old] ,am]icans ,act ( #aife7 & !  
protection & advocacy sy/em 7z def9$ 9  
section #ajb ( ! ,developm5tal          
,disabilities ,assi/ance & ,bill (      
,rights ,act ( #bjjj72 &  7,,iv7 ! nurs+
 facility t is grant$ ! waiv] by a ,/ate
 notifies resid5ts ( ! facility 7or1 :]e
 appropriate1 ! gu>dians or legal       
repres5tatives ( su* resid5ts7 & memb]s 
( _! imm$iate families ( ! waiv]4  7ii7 
,annual review ,a waiv] "u ?is          
subp>agraph %all be subject to annual   
review by ! ,/ate ag5cy & to ! review ( 
! ,secret>y & subject to clause 7iii7   
%all be accept$ by ! ,secret>y =        
purposes ( ?is title to ! same ext5t z  
is ! ,/ate's c]tification ( ! facility4 
,9 grant+ or r5ew+ a waiv]1 a ,/ate may 
require ! facility to use o!r qualifi$1 
lic5s$ p]sonnel to meet ! /aff+         
requirem5ts "u subp>agraph 7,a77iii74   
7iii7 ,assumption ( waiv] au?ority by   
,secret>y ,if ! ,secret>y det]m9es t a  

,/ate has %[n a cle> patt]n & practice (
 all[+ waiv]s 9 ! abs5ce ( dilig5t ef=ts
 by facilities to meet ! /aff+          
requirem5ts "u subp>agraph 7,a77iii71 ! 
,secret>y %all assume & ex]cise !       
au?ority ( ! ,/ate to grant waiv]s4  4  
7c7 ,effective date ,! am5dm5ts made by 
?is section %all take effect on ,octob] 
#a1 #bjbb4  #bjf4 ,enhanc$ fund+ to     
support /aff+ & quality c>e 9 nurs+     
facilities  7a7 ,,fmap increase  7#a7 ,9
 g5]al ,not)/&+ subsection 7b7 or 7ff7 (
 section #aije ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acif;d71 9 ! case (
 a ,/ate t meets ! requirem5ts describ$ 
9 subsection 7c71 ! ,f$]al m$ical       
assi/ance p]c5tage det]m9$ = ! ,/ate "u 
subsection 7b7 ( section #aije ( su*    
,act 7or subsection 7ff7 ( su* section1 
if applicable7 &1 if applicable1 z      
increas$ "u subsection 7y71 7z71 7aa71  
or 7ii7 ( su* section or section #fjjh (
 ! ,families ,fir/ ,coronavirus         
,response ,act 7,public ,law #aaf-abg71 
or any o!r provision ( law1 %all be     

increas$ by ! applicable numb] (        
p]c5tage po9ts specifi$ 9 p>agraph 7#b7 
7b n to exce$ #ie p]c5t7 ) respect to   
am\nts exp5d$ by ! ,/ate ,m$icaid       
program = m$ical assi/ance = nurs+      
facility s]vices provid$ = ea* cal5d>   
qu>t] t occurs dur+ ! applicable p]iod &
 = :i* ! ,secret>y det]m9es t ! ,/ate   
meets su* requirem5ts4 ,any paym5t made 
to ,pu]to ,rico1 ! ,virg9 ,isl&s1 ,guam1
 ! ,nor!rn ,m>iana ,isl&s1 or ,am]ican  
,samoa = exp5ditures on m$ical assi/ance
 t are subject to ! ,f$]al m$ical       
assi/ance p]c5tage increase specifi$ "u 
! fir/ s5t5ce ( ?is p>agraph %all n be  
tak5 into acc\nt = purposes ( apply+    
paym5t limits "u subsections 7f7 & 7g7 (
 section #aajh ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acjh74  7#b7       
,applicable numb] ( p]c5tage po9ts ,=   
purposes ( p>agraph 7#a71 ! applicable  
numb] ( p]c5tage po9ts specifi$ 9 ?is   
p>agraph is-- 7,a7 9 ! case ( a cal5d>  
qu>t] t occurs )9 ! #af-qu>t] p]iod t   
beg9s on ! #a/ day ( ! applicable p]iod1

 #c p]c5tage po9ts2  7,b7 9 ! case ( a  
cal5d> qu>t] t occurs )9 ! #d-qu>t]     
p]iod imm$iately succe$+ su* #af-qu>t]  
p]iod1 #b p]c5tage po9ts2 &  7,c7 9 !   
case ( a cal5d> qu>t] t occurs )9 !     
#d-qu>t] p]iod imm$iately succe$+ !     
#d-qu>t] p]iod describ$ 9 subp>agraph   
7,b71 #a p]c5tage po9t4  7b7 ,def9itions
 ,9 ?is section3 7#a7 ,applicable p]iod 
,! t]m applicable p]iod means ! p]iod   
t-- 7,a7 beg9s on ! #a/ day ( ! #a/     
cal5d> qu>t] t beg9s on or aft] ! date t
 is #a ye> aft] ! date ( enactm5t ( ?is 
section2 &  7,b7 ends on ! la/ day ( !  
succe$+ #bd? cal5d> qu>t]4  7#b7 ,nurs+ 
facility /aff ,! t]m nurs+ facility /aff
 includes a regi/]$ nurse1 lic5s$       
practical nurse1 lic5s$ nurs+ assi/ant1 
c]tifi$ nurs+ assi/ant1 nurs+ assi/ant1 
& any o!r relevant /aff1 z det]m9$ by ! 
,secret>y1 :o provide c>e to ,m$icaid   
b5efici>ies :o are resid5ts 9 a nurs+   
facility4  7#c7 ,m$icaid b5efici>y ,!   
t]m ,m$icaid b5efici>y means an         
individual :o is eligible =1 & enroll$  

91 a ,/ate ,m$icaid program4  7#d7      
,m$icaid program ,! t]m ,m$icaid program
 means1 ) respect to a ,/ate1 ! ,/ate   
program "u title ,,xix ( ! ,social      
,security ,act 7#db ,u4,s4,c4 #acif et  
seq47 7includ+ any waiv] or demon/ration
 "u su* title or "u section #aaae ( su* 
,act 7#db ,u4,s4,c4 #acae7 relat+ to su*
 title74  7#e7 ,nurs+ facility ,! t]m   
nurs+ facility-- 7,a7 has ! mean+ giv5  
su* t]m 9 section #aiai7;a7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4 #acifr7a72
 &  7,b7 includes a skill$ nurs+        
facility1 z def9$ 9 section #ahai7;a7 ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#acie;i-#c7;a771 t is a p>ticipat+      
provid] 9 ! ,m$icaid program ( ! ,/ate 9
 :i* ! facility is locat$ or o!rwise    
furni%es items or s]vices = :i* m$ical  
assi/ance is available "u ! ,m$icaid    
program ( ! ,/ate 9 :i* ! facility is   
locat$4  7#f7 ,nurs+ facility s]vices   
7,a7 ,9 g5]al ,subject to subp>agraphs  
7,b7 & 7,c71 ! t]m nurs+ facility       
s]vices has ! mean+ giv5 su* t]m "u     

section #aije7;f7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #acif;d7f774  7,b7  
,/ate m$icaid program ,) respect to a   
,/ate1 su* t]m includes ^? s]vices      
7includ+ any limitations on ! provision 
(1 or paym5t =1 su* s]vices7 t are      
specifi$ z nurs+ facility s]vices =     
purposes ( ! ,m$icaid program ( ! ,/ate 
9 :i* ! nurs+ facility furni%+ su*      
s]vices is locat$4  7,c7 ,individual    
plan ( c>e ,not)/&+ subp>agraph 7,a7 or 
7,b71 su* t]m includes items or s]vices 
t are specifi$ 9 ! individual plan ( c>e
 = a resid5t ( a nurs+ facility & are   
furni%$ to ! resid5t 9 accordance ) !   
requirem5ts ( su* plan4  7#g7 ,secret>y 
,! t]m ,secret>y means ! ,secret>y (    
,heal? & ,human ,s]vices4  7#h7 ,/ate ,!
 t]m ,/ate has ! mean+ giv5 su* t]m =   
purposes ( title ,,xix ( ! ,social      
,security ,act 7#db ,u4,s4,c4 #acif et  
seq474  7c7 ,requirem5ts ,z a condition 
= receipt ( ! increase "u subsection 7a7
 to ! ,f$]al m$ical assi/ance p]c5tage  
det]m9$ = a ,/ate "u subsection 7b7 (   

section #aije ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acif;d7 = a cal5d>     
qu>t]1 ! ,/ate %all demon/rate to !     
satisfaction ( ! ,secret>y ! foll[+3    
7#a7 ,use ( additional f$]al funds ,!   
,/ate agrees to-- 7,a7 use ! ,f$]al     
funds attributable to ! increase "u     
subsection 7a7 only = ! purposes        
specifi$ 9 subsection 7d72 &  7,b7 n use
 su* ,f$]al funds to satisfy any ,/ate  
contribution requir$ "u ! ,/ate ,m$icaid
 program4  7#b7 ,plan = /aff+ & s]vice  
improvem5ts & report+ ,! ,/ate has a    
reasonable plan = a*iev+ ! purposes     
specifi$ 9 subsection 7d71 includ+ )    
respect to-- 7,a7 c>ry+ out ! /aff+ &   
s]vice improvem5ts specifi$ 9 subsection
 7e7 to /r5g!n nurs+ facility /aff      
work=ce & improve ! quality & safety (  
c>e = ,m$icaid b5efici>ies2 &  7,b7     
collect+ & report+ ! in=mation requir$  
"u subsection 7f74  7#c7 ,supplem5t1 n  
supplant ,! ,/ate agrees to use ! ,f$]al
 funds attributable to ! increase "u    
subsection 7a7 to supplem5t1 & n        

supplant1 ! level ( ,/ate funds exp5d$ z
 ( ,octob] #a1 #bjba1 = nurs+ facility  
s]vices1 includ+ ) respect to ef=ts to  
/r5g!n ! nurs+ facility /aff work=ce &  
improve ! quality & safety ( c>e =      
,m$icaid b5efici>ies1 "u ! ,/ate        
,m$icaid program4  7#d7 ,report+ &      
ov]sight ,! ,/ate agrees to-- 7,a7      
annually report ! in=mation specifi$ 9  
subsection 7f7 to ! ,secret>y 9 su* =m &
 mann] z ! ,secret>y %all require2 &    
7,b7 provide su* data & in=mation z is  
necess>y = ! evaluation requir$ "u      
subsection 7g74  7d7 ,use ( funds ,a    
,/ate may use ! ,f$]al funds            
attributable to ! increase "u subsection
 7a7 only = exp5ditures eligible =      
paym5t "u ! ,/ate ,m$icaid program t are
 attributable to ,/ate ef=ts to a*ieve  
bo? ( ! foll[+ purposes3 7#a7 ,to exp& &
 improve nurs+ facility /aff+1 includ+  
by increas+ paym5ts = nurs+ facility    
s]vices to improve /aff wages & b5efits1
 support ret5tion & recruitm5t1 & r$uce 
/aff turnov]1 consi/5t ) ! improvem5ts  

specifi$ 9 p>agraphs 7#a7 & 7#b7 (      
subsection 7e74  7#b7 ,to support &     
improve ! quality & safety ( c>e provid$
 to ,m$icaid b5efici>ies 9 nurs+        
facilities1 includ+ ?r\gh ef=ts to exp& 
! use ( p]son-c5t]$ models ( c>e1 &     
inc5tives or paym5ts relat$ to !        
provision ( c>e = ,m$icaid b5efici>ies 9
 private rooms4  7e7 ,/aff+ & s]vice    
improvem5ts ,! /aff+ & s]vice           
improvem5ts specifi$ 9 ?is subsection   
are ! foll[+3 7#a7 ,! ,/ate makes su*   
*anges to processes = det]m9+ paym5t    
rates = nurs+ facility s]vices z are    
necess>y to ensure t-- 7,a7 su* paym5t  
rates are review$ & updat$ e #b ye>s    
dur+ ! applicable p]iod to support !    
recruitm5t & ret5tion ( nurs+ facility  
/aff1 & r$uce turnov] 9 su* /aff ?r\gh a
 transp>5t process t involves mean+ful  
input f /akehold]s2 &  7,b7 increases to
 su* paym5t rates are1 at a m9imum1 us$ 
to proportionally increase wages &      
b5efits = nurs+ facility /aff4  7#b7 ,! 
,/ate updates1 develops1 & adopts tra9+ 

opportunities & res\rces = nurs+        
facility /aff1 includ+ tra9+ = provid+  
p]son-c5t]$ c>e4  7#c7 ,! ,/ate improves
 & /reaml9es education & options c\nsel+
 s]vices = ,m$icaid b5efici>ies1        
pot5tial ,m$icaid b5efici>ies1 & family 
memb]s ( su* b5efici>ies & pot5tial     
b5efici>ies1 ) respect to eligibility & 
options = in/itutional &                
non-in/itutional long t]m c>e4  7f7     
,annually report$ in=mation ,! in=mation
 requir$ to be annually report$ to !    
,secret>y by a ,/ate ) respect to su*   
report+ p]iods z ! ,secret>y %all       
specify is ! foll[+3 7#a7 ,! numb] (    
,m$icaid b5efici>ies :o receiv$ dur+ !  
report+ p]iod or1 z ( ! date ( ! report1
 are receiv+1 nurs+ facility s]vices 9 !
 ,/ate1 disaggregat$ by race1 e?nicity1 
g5d]1 geography1 age1 & income4  7#b7 ,a
 description ( h[ ! ,/ate sp5t ! ,f$]al 
funds attributable to ! increase "u     
subsection 7a7 dur+ ! report+ p]iod4    
7#c7 ,*anges to paym5t rates = nurs+    
facility s]vices "u ! ,/ate ,m$icaid    

program dur+ ! report+ p]iod4  7#d7 ,!  
/aff+ in=mation & employee turnov] &    
t5ure in=mation 9 nurs+ facilities 9 !  
,/ate dur+ ! report+ p]iod1 bas$ on     
submissions to ! ,payroll-,bas$ ,j\rnal 
sy/em ( ! ,c5t]s = ,m$ic>e  ,m$icaid    
,s]vices "u section #aabh;,i7g7 ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#acbj;a-#g;j7g774  7#e7 ,! wages &      
b5efits provid$ to nurs+ facility /aff 9
 nurs+ facilities 9 ! ,/ate dur+ !      
report+ p]iod4  7#f7 ,a description ( ! 
heal? /atus (1 & quality ( c>e provid$  
to1 ,m$icaid b5efici>ies :o are resid5ts
 ( nurs+ facilities 9 ! ,/ate dur+ !    
report+ p]iod1 9 ! mann] det]m9$ by !   
,secret>y4  7g7 ,evaluation ,! ,secret>y
 %all engage an ext]nal contractor to   
conduct an indep5d5t evaluation ( !     
impact ( ?is section on-- 7#a7 ! quality
 & safety ( c>e provid$ 9 nurs+         
facilities to ,m$icaid b5efici>ies :o   
are resid5ts ( nurs+ facilities2  7#b7 !
 capacity ( ! nurs+ facility /aff       
work=ce to provide quality1 safe c>e =  

,m$icaid b5efici>ies :o are resid5ts (  
nurs+ facilities2 &  7#c7 ! wages1      
b5efits1 & turnov] ( nurs+ facility     
/aff4  7h7 ,int]im & f9al reports to    
,congress  7#a7 ,9 g5]al ,! ,secret>y   
%all submit an int]im report to         
,congress on ! implem5tation ( ?is      
section #d ye>s aft] ! date ( enactm5t (
 ?is section1 & a f9al report on !      
implem5tation ( ?is section #h ye>s aft]
 su* date4  7#b7 ,requir$ in=mation     
7,a7 ,int]im & f9al reports ,! int]im & 
f9al reports submitt$ "u ?is subsection 
%all include ! foll[+ in=mation3 7i7 ,! 
numb] ( ,/ates t receiv$ an increase to 
! ,f$]al m$ical assi/ance p]c5tage ( !  
,/ate "u subsection 7a7 dur+ !          
applicable p]iod4  7ii7 ,! ,/ate        
activities fund$ by ! ,f$]al funds      
attributable to ! increase "u subsection
 7a74  7,b7 ,f9al report ,! f9al report 
submitt$ "u ?is section %all include1 9 
addition to ! in=mation requir$ "u      
subp>agraph 7,a71 ! results ( !         
indep5d5t evaluation conduct$ pursuant  

to subsection 7g74  ,,iii ,build+       
modification & /aff inve/m5t            
demon/ration program  #cja4 ,e/abli%+ a 
skill$ nurs+ facility build+            
modification & /aff inve/m5t            
demon/ration program ,"p ,a ( title     
,,xviii ( ! ,social ,security ,act 7#db 
,u4,s4,c4 #acie;c et seq47 is am5d$ by  
ins]t+ aft] section #ahai ! foll[+ new  
section3  #ahai;,a4 ,community-bas$ liv+
 modifications & /aff inve/m5t          
demon/ration program  7a7 ,e/abli%m5t ,n
 lat] ?an ,janu>y #a1 #bjbc1 ! ,secret>y
 %all e/abli% a demon/ration program to 
te/ ! impact ( provid+ skill$ nurs+     
facilities 7z def9$ 9 section #ahai7;a77
 select$ by ! ,secret>y "u subsection   
7b7 fund+ to modify ! built environm5ts 
( su* facilities 7or portions ( su*     
facilities7 & inve/ 9 individuals       
provid+ resid5t c>e 9 su* facilities 7or
 9 portions ( su* facilities7 9 ord] to1
 ) respect to resid5ts ( su* facilities1
 improve heal? outcomes relative to     
resid5ts ( facilities n s select$4  7b7 

,application & selection ( facilities   
7#a7 ,application  7,a7 ,9 g5]al ,a     
skill$ nurs+ facility %all only be      
eligible to receive fund+ "u !          
demon/ration program e/abli%$ "u        
subsection 7a7 if su* facility submits  
an application at su* "t & 9 su* mann] z
 specifi$ by ! ,secret>y t conta9s-- 7i7
 a description ( modifications &        
inve/m5ts describ$ 9 subsection 7a7 t w 
be made by ! facility us+ su* funds1    
includ+ ! e/imat$ co/s ( su*            
modifications & inve/m5ts2  7ii7 an     
agreem5t t su* facility 7or1 9 ! case   
su* modifications & inve/m5ts are to be 
made only ) respect to a portion ( su*  
facility1 su* portion ( su* facility7-- 
7,i7 w meet ! requirem5ts describ$ 9    
subp>agraph 7,b7 n lat] ?an ! date t is 
#b ye>s aft] su* facility fir/ receives 
funds = su* modifications & inve/m5ts "u
 su* program2 &  7,,ii7 w cont9ue to    
meet su* requirem5ts = ! #e-ye> p]iod   
beg9n+ on ! date t is #b ye>s aft] su*  
facilities fir/ receives su* funds2     

7iii7 an agreem5t t1 9 ! case su*       
facility 7or su* portion ( su* facility1
 z applicable7 fails to meet su*        
requirem5ts 9 accordance ) clause 7ii71 
su* facility w-- 7,i7 repay su* funds to
 ! ,secret>y 9 an am\nt det]m9$         
appropriate by ! ,secret>y "u subsection
 7d72 &  7,,ii7 notify ea* resid5t ( su*
 facility 7or ea* resid5t ( su* portion 
( su* facility1 z applicable7 ( !       
failure ( su* facility or su* portion1 z
 applicable1 to meet su* requirem5ts2   
7iv7 an agreem5t t1 if su* facility is  
select$ by ! ,secret>y "u p>agraph 7#b71
 ! facility w notify ea* resid5t ( su*  
facility 7or ea* resid5t ( su* portion (
 su* facility1 z applicable71 ( su*     
selection & include 9 su* notification a
 description ( ! program e/abli%$ "u    
subsection 7a71 includ+ any             
modifications & inve/m5ts to be made )  
respect to su* facility 7or ) respect to
 su* portion ( su* facility1 z          
applicable72 &  7v7 9 ! case su*        
modifications & inve/m5ts are to be made

 only ) respect to a portion ( su*      
facility1 an agreem5t t su* facility w n
 discrim9ate 9 ! selection ( resid5ts :o
 may reside 9 su* portion bas$ on :e!r  
paym5t is be+ made to su* facility )    
respect to su* resid5t "u ?is title1 a  
,/ate plan 7or waiv] ( su* plan7 "u     
title ,,xix1 or o!rwise4  7,b7          
,requirem5ts ,= purposes ( subp>agraph  
7,a71 ! requirem5ts describ$ 9 ?is      
subp>agraph ) respect to a skill$ nurs+ 
facility 7or a portion ( su* facility7  
are ! foll[+3 7i7 ,! facility 7or       
portion7 ma9ta9s b$s = no less ?an #e & 
no m ?an #ad resid5ts4  7ii7 ,! facility
 7or portion7 incorporates univ]sal     
design 7def9$ 9 section #c7ai7 ( !      
,assi/ive ,te*nology ,act ( #aiih77 to  
ensure su* facility 7or portion7 is     
accessible to all resid5ts1 reg>dless ( 
age or disability1 includ+ by provid+ = 
! foll[+3 7,i7 ,private rooms & ba?rooms
 7unless su* facility det]m9es t !      
provision ( private rooms & ba?rooms at 
su* facility w\ld adv]sely affect !     

availability ( skill$ nurs+ facility    
s]vices 9 ! area 9 :i* su* facility is  
locat$ & ! ,secret>y concurs ) su*      
det]m9ation74  7,,ii7 ,%>$ space1       
includ+ a c5tral liv+ area1 z def9$ by !
 ,secret>y1 ) a communal d9+ table &    
accessible kit*54  7,,iii7 ,accessible  
outdoor space1 includ+ a protect$ g>d5  
space = use by resid5ts & _! visitors4  
7iii7 ,! facility 7or portion7 provides 
a cl9ical team t consi/s ( a full-"t    
regi/]$ pr(essional nurse or lic5s$     
practical nurse 7or lic5s$ vocational   
nurse7 :o works 9 p>tn]%ip ) c]tifi$    
nurs+ assi/ants 9 a team-bas$1          
collaborative model4  7iv7 ,! facility  
7or portion7 has a lic5s$ practical     
nurse 7or lic5s$ vocational nurse7 on   
site at all times4  7v7 ,! facility 7or 
portion7 facilitates a /&+ resid5t      
c\ncil run by resid5ts1 & a /&+ family  
c\ncil run by family memb]s ( resid5ts1 
t meets su* requirem5ts z may be        
specifi$ by ! ,secret>y4  7vi7 ,!       
facility 7or portion7 solicits resid5t  

input on facility policies 7or policies 
relat+ to su* portion ( su* facility71  
includ+ ) respect to programs & s*$ul+1 
&1 9 ! case ( an incapacitat$ resid5t1  
solicits su* input f an individual      
recogniz$ by ,/ate law to act on behalf 
( su* resid5t4  7vii7 ,9 addition to !  
resid5t assessm5t "u section            
#ahai7;b77#c71 ! facility 7or portion7  
conducts an assessm5t ( resid5ts' c>e   
pref]5ces 7or1 9 ! case ( an            
incapacitat$ resid5t1 su* pref]5ces z   
express$ by an individual recogniz$ by  
,/ate law to act on behalf ( su*        
resid5t7 n lat] ?an #ad days aft] !     
resid5t is admitt$ to su* facility or   
portion ( su* facility 7or1 9 ! case ( a
 resid5t resid+ at su* facility at ! "t 
su* facility receives fund+ "u ! program
 e/abli%$ "u p>agraph 7#a71 n lat] ?an  
#ad days aft] ! date ( su* receipt7 to  
ensure c>e is p]son-direct$4  7viii7 ,! 
facility 7or portion7 (f]s daily        
activities1 su* z art1 music1           
educational activities1 or o!r          

activities bas$ on resid5t pref]5ces4   
7,c7 ,timeframe ,! ,secret>y %all       
develop ! application describ$ 9        
subp>agraph 7,a7 & beg9 accept+ su*     
applications n lat] ?an ,july #a1 #bjbc4
 ,! ,secret>y %all accept su*           
applications dur+ ! #b-ye> p]iod beg9n+ 
on ! date su* applications are fir/     
accept$4  7#b7 ,selection  7,a7 ,9 g5]al
 ,n lat] ?an #b ye>s aft] ! date !      
,secret>y fir/ accepts applications "u  
p>agraph 7#a71 ! ,secret>y %all select a
 numb] ( skill$ nurs+ facilities det]m9$
 appropriate by ! ,secret>y to receive  
fund+ "u ! program e/abli%$ "u          
subsection 7a74  7,b7 ,pref]5ce ,9      
select+ skill$ nurs+ facilities "u ?is  
p>agraph1 ! ,secret>y %all-- 7i7 give   
pref]5ce to facilities t-- 7,i7 are     
locat$ 9 m$ically und]s]v$ areas 7z     
def9$ 9 section #ccj7;b77#c77;,a7 ( !   
,public ,heal? ,s]vice ,act72 &  7,,ii7 
h\se a majority ( resid5ts :o are       
receiv+ m$ical assi/ance consi/+ ( nurs+
 facility s]vices "u a ,/ate plan 7or   

waiv] ( su* plan7 "u title ,,xix2  7ii7 
give pref]5ce to facilities t demon/rate
 ! greate/ likelihood ( meet+ !         
requirem5ts describ$ 9 p>agraph         
7#a77;,b7 )9 #b ye>s ( receiv+ fund+ "u 
! program e/abli%$ "u subsection 7a72   
7iii7 give pref]5ce to facilities t (f] 
/aff tra9+ beyond su* tra9+ requir$ "u  
section #ahai 7z det]m9$ ?r\gh payroll  
bas$ j\rnal data72 &  7iv7 s select su* 
facilities 9 a mann] t ensures          
geographic div]sity1 to ! ext5t         
practicable4  7c7 ,funds  7#a7 ,9 g5]al 
,subject to p>agraph 7#c7 & subsection  
7h71 ! ,secret>y %all provide funds to  
ea* skill$ nurs+ facility select$ "u    
subsection 7b77#b7 9 an am\nt equal to n
 m ?an ! co/s specifi$ by su* facility  
pursuant to subsection 7b77#a77;,a77i74 
7#b7 ,use ( funds  7,a7 ,9 g5]al        
,subject to subp>agraph 7,b71 funds     
provid$ "u p>agraph 7#a7 may only be us$
 by a skill$ nurs+ facility =           
modifications & inve/m5ts specifi$ by   
su* facility pursuant to subsection     

7b77#a77;,a77i74  7,b7 ,exception ,a    
skill$ nurs+ facility may use funds     
provid$ "u p>agraph 7#a7 = modifications
 & inve/m5ts describ$ 9 subsection 7a7 b
 n specifi$ by su* facility pursuant to 
subsection 7b77#a77;,a77i7 if-- 7i7 su* 
facility submits a reque/ to ! ,secret>y
 conta9+ a description ( su*            
modifications & inve/m5ts2 &  7ii7 !    
,secret>y det]m9es t su* modifications &
 inve/m5ts w assi/ su* facility 7or a   
portion ( su* facility1 z applicable7 9 
comply+ ) ! requirem5ts specifi$ 9      
subsection 7b77#a77;,b74  7#c7 ,=m (    
provision ( funds ,! ,secret>y may      
provide fund+ "u p>agraph 7#a7 9 ! =m ( 
a s+le upfront paym5t or 9 up to #c     
in/allm5t paym5ts1 spac$ out across !   
fir/ #c fiscal ye>s beg9n+ ) ! fiscal   
ye> 9 :i* ! fir/ su* paym5t is made4    
7#d7 ,limitation ( provision ( fund+ ,no
 skill$ nurs+ facility may receive m ?an
 #c p]c5t ( ! total monies appropriat$  
"u p>agraph 7#e74  7#e7 ,appropriation  
,9 addition to any am\nts o!rwise       

available1 !re is appropriat$ to !      
,secret>y1 out ( any monies 9 !         
,treasury n o!rwise appropriat$1        
#a1cjj1jjj1jjj1 to rema9 available until
 exp5d$1 = purposes ( provid+ funds to  
skill$ nurs+ facilities "u p>agraph     
7#a74  7d7 ,failure ,to meet requirem5ts
  7#a7 ,9 g5]al ,subject to p>agraph    
7#b71 9 ! case ( a facility 7or a       
portion ( su* facility1 z applicable7 t 
fails to meet ! requirem5ts describ$ 9  
subsection 7b77#a77;,b7 9 accordance ) !
 agreem5t describ$ 9 subsection         
7b77#a77;,a77ii71 ! ,secret>y may rec\p 
any funds provid$ to su* facility "u    
subsection 7c77#a7 9 an am\nt det]m9$   
appropriate by ! ,secret>y4 ,9 det]m9+  
su* am\nt1 ! ,secret>y %all take into   
acc\nt ! ext5t ( ! compliance ( su*     
facility 7or portion ( su* facility1 z  
applicable7 ) su* requirem5ts4  7#b7    
,exception ,! ,secret>y may susp5d any  
rec\pm5t describ$ 9 p>agraph 7#a7 )     
respect to a facility 7or a portion (   
su* facility1 z applicable7 describ$ 9  

su* p>agraph = a p]iod ( "t det]m9$     
appropriate by ! ,secret>y if !         
,secret>y f9ds t su* facility 7or su*   
portion7 w likely be 9 compliance ) !   
requirem5ts describ$ 9 su* p>agraph )9 a
 reasonable "t specifi$ by ! ,secret>y4 
7e7 ,evaluation ( program  7#a7 ,9 g5]al
 ,! ,secret>y %all evaluate ea* skill$  
nurs+ facility receiv+ funds "u !       
program e/abli%$ "u subsection 7a7 to   
assess :e!r1 relative to simil>ly       
situat$ skill$ nurs+ facilities n       
receiv+ funds "u su* program & resid5ts 
( su* facilities1 modifications &       
inve/m5ts describ$ 9 subsection 7a7 made
 at skill$ nurs+ facilities us+ su*     
funds result$ 91 ) respect to resid5ts (
 su* facilities 7or1 9 ! case su*       
modifications & inve/m5ts are made only 
) respect to a portion ( su* facility1  
resid5ts ( su* portion ( su* facility7--
 7,a7 a r$uction 9 prev5table           
hospitalizations2  7,b7 a r$uction 9    
hospital readmissions2  7,c7 a r$uction 
9 em]g5cy room visits2  7,d7 great]     

improvem5t 9 functional /atus2  7,e7 an 
improvem5t 9 infection control2  7,f7 a 
r$uction 9 nurs+ /aff turnov] rates2    
7,g7 an increase 9 resid5t & family     
c>egiv] satisfaction2  7,h7 o!r         
improvem5ts 9 resid5t quality ( life z  
may be specifi$ by ! ,secret>y2  7,i7 a 
r$uction 9 exp5ditures "u ?is "p        
7exclud+ funds provid$ "u subsection    
7c77#a772 or  7,j7 any o!r outcomes     
specifi$ by ! ,secret>y4  7#b7 ,reports 
to ,congress ,bas$ on evaluations       
describ$ 9 p>agraph 7#a71 ! ,secret>y   
%all1 n lat] ?an ,july #a1 #bjca1 & aga9
 n lat] ?an ,july #a1 #bjce1 submit to  
,congress a report on su* program4 ,ea* 
su* report %all include an analysis ( ! 
demon/ration program's effect on !      
outcomes describ$ 9 p>agraph 7#a74  7f7 
,implem5tation ,*apt] #ce ( title #dd1  
,unit$ ,/ates ,code1 %all n apply to ?is
 section4  7g7 ,au?ority ,to exp& to    
c]ta9 nurs+ facilities ,! ,secret>y may1
 subject to subsection 7h71 ent] into   
agreem5ts ) ,/ates to include nurs+     

facilities 7z def9$ 9 section #aiai7;a77
 t are n skill$ nurs+ facilities 7z     
def9$ 9 section #ahai7;a77 9 !          
demon/ration program e/abli%$ "u        
subsection 7a7 & may modify !           
requirem5ts ( ! previ\s provisions ( ?is
 section z appropriate to be applicable 
to su* facilities4  7h7 ,fund+ ,!       
,secret>y %all provide = ! transf]1 f ! 
,f$]al ,hospital ,insurance ,tru/ ,fund 
"u #ahag to ! ,c5t]s = ,m$ic>e  ,m$icaid
 ,s]vices ,program ,managem5t ,acc\nt1 (
 #cj1jjj1jjj = fiscal ye> #bjbc =       
purposes ( c>ry+ out ?is section 7o!r   
?an = purposes ( mak+ paym5ts "u        
subsection 7c77#a774 ,am\nts transf]r$  
pursuant to ! previ\s s5t5ce %all rema9 
available until exp5d$4  4