,i  #aahth ,,congress  #b;d ,session    
,h4 ,r4 #hcca  ,,in ,,the ,,house ,,of  
,,representatives  ,may #h1 #bjbd,ms4   
,tenney 7for herself1 ,mr4 ,larson of   
,connecticut1 ,mr4 ,fitzpatrick1 ,mr4   
,smith of ,nebraska1 ,mr4 ,rutherford1  
,mr4 ,van ,orden1 ,ms4 ,wild1 ,mr4      
,carey1 ,mr4 ,lawler1 ,mr4 ,cleaver1    
,ms4 ,lee of ,nevada1 ,mr4 ,ciscomani1  
,mr4 ,bacon1 ,mr4 ,davis of ,north      
,carolina1 ,mr4 ,cohen1 and ,mr4        
,langworthy7 introduced the following   
bill2 which was referred to the         
,committee on ,energy and ,commerce1 and
 in addition to the ,committee on ,ways 
and ,means1 for a period to be          
subsequently determined by the ,speaker1
 in each case for consideration of such 
provisions as fall within the           
jurisdiction of the committee concerned 
,a ,,bill  ,to amend titles ,,xviii and 
,,xix of the ,social ,security ,act to  
require skilled nursing facilities1     
nursing facilities1 intermediate care   
facilities for the intellectually       

disabled1 and inpatient rehabilitation  
facilities to permit essential          
caregivers access during any period in  
which regular visitation is restricted4 
#a4 ,short title ,this ,act may be cited
 as the ,essential ,caregivers ,act of  
#bjbd4  #b4 ,findings ,congress finds   
the following3  7#a7 ,according to the  
,national ,center for ,health           
,statistics of the ,centers for ,disease
 ,control and ,prevention1 an estimated 
#a1cjj1jjj individuals resided in       
nursing homes in #bjbj at the onset of  
the ,,covid-#ai pandemic and nearly half
 of all nursing home residents were     
living with a diagnosis of ,alzheimer's 
or other related dementia4  7#b7        
,regulations issued pursuant to the     
,nursing ,home ,reform ,act of #aihg    
established basic rights and services   
for residents of nursing homes1         
including the right to a dignified      
existence1 self-determination1 and      
communication with and access to persons
 and services inside and outside the    

facility4  7#c7 ,in ,march of #bjbj1 the
 ,centers for ,medicare  ,medicaid      
,services instructed nursing facilities 
to restrict visitation for all visitors 
and non-essential healthcare personnel  
and cancel communal dining and group    
activities4 ,long-term care ombudsman   
program representatives and ,state      
surveyors were among those whose access 
to long-term care facilities was        
prohibited or extremely restricted      
despite reopening guidance released by  
the ,centers for ,medicare  ,medicaid   
,services in ,may of #bjbj4  7#d7 ,many 
long-term care residents declined       
dramatically or died prematurely from   
failure to thrive in isolation4  7#e7   
,according to the ,national ,consumer   
,voice for ,quality ,long-,term ,care1  
in the first year of the ,,covid-#ai    
pandemic1 #a in #e healthcare workers   
resigned1 retired1 or were fired4 ,this 
exacerbated the longstanding problem of 
staff shortages that already existed4   
,lack of staff1 combined with the forced

 absence of families1 many of whom      
provided informal care and support to   
residents1 resulted in a significant    
decline in residents' health and        
well-being4 ,during the pandemic1       
pressure ulcers in nursing home         
residents rose by #ca percent1 the      
number of residents experiencing        
significant weight loss rose by #di     
percent1 the number of residents        
reporting feeling down1 depressed1 or   
hopeless rose by #dj percent1 and the   
number of residents prescribed          
antipsychotic medications rose by #gg4e 
percent4  7#f7 ,according to the        
,department of ,health and ,human       
,services1 loneliness and isolation1    
such as that experienced by long-term   
care residents during the ,,covid-#ai   
pandemic1 represent profound threats to 
an individual's health and well-being4  
7#g7 ,essential ,caregivers provide     
supplemental care for their loved one1  
regardless of staff shortages1 staff    
turnover1 or emergencies4 ,essential    

,caregivers support residents and       
advocate on their behalf4  #c4 ,right to
 essential caregivers2 access to        
essential caregivers during periods when
 visitation is otherwise restricted  7a7
 ,medicare skilled nursing facilities   
,section #ahai7;c77#c7 of the ,social   
,security ,act 7#db ,u4,s4,c4           
#acie;i-#c7;c77#c77 is amended--  7#a7  
by redesignating subparagraphs 7,a7     
through 7,e7 as clauses 7i7 through 7v71
 respectively2  7#b7 by striking ,a     
skilled nursing facility must-- and     
inserting the following3  7,a7 ,in      
general ,a skilled nursing facility     
shall--  2 and  7#c7 by adding at the   
end the following new subparagraph3     
7,b7 ,access to essential caregivers    
during emergency periods when visitation
 is otherwise restricted  7i7           
,designation of essential caregiver     
,each skilled nursing facility shall    
recognize the right of each resident of 
such facility to-- 7,i7 designate and   
have access to essential caregivers for 

such resident at all times1 including   
during any period of emergency in which 
regular visitation is restricted by     
order of a ,federal1 ,state1 or local   
authority or by other operation of law2 
and  7,,ii7 amend such designation at   
any time4  7ii7 ,presumption of         
designation ,for purposes of clause 7i71
 in the case of a resident who is       
unable1 by reason of cognitive or mental
 disability1 to make an election        
described in such clause1 the resident  
representative 7as defined in section   
#dhc4e of title #db1 ,code of ,federal  
,regulations7 of such resident shall be 
permitted to make such designation for  
such resident4  7iii7 ,access to        
essential caregivers during emergency   
periods when visitation is otherwise    
restricted ,during a period of emergency
 in which regular visitation is         
restricted by order of a ,federal1      
,state1 or local authority or by other  
operation of law1 including any period  
in which a waiver or modification of    

requirements pursuant to section #aace  
is in effect1 a skilled nursing facility
 shall-- 7,i7 not deny in-person access 
to a resident by an essential caregiver 
of the resident except as provided in   
this subparagraph2  7,,ii7 allow at     
least #a essential caregiver to have    
access to and provide assistance to such
 resident at such facility every day and
 at any time2 and  7,,iii7 enforce the  
agreement described in clause           
7vii77,,iii7 with respect to an         
essential caregiver4  7iv7 ,restrictions
 on access  7,i7 ,in general ,during a  
period of emergency in which regular    
visitation is restricted by order of a  
,federal1 ,state1 or local authority or 
by other operation of law1 including any
 period in which a waiver or            
modification of requirements pursuant to
 section #aace is in effect1 a skilled  
nursing facility may deny access to a   
resident by an essential caregiver of   
the resident for-- 7aa7 an initial      
period of not longer than #g days2 and  

7bb7 one additional period of not longer
 than #g days 7in addition to the       
initial period described in item 7aa77  
if the department of health of the      
,state in which the facility is located 
approves the denial of access for such  
additional period4  7,,ii7 ,rule of     
application ,for purposes of subclause  
7,i71 a period of emergency in which    
regular visitation is restricted by     
order of a ,federal1 ,state1 or local   
authority or by other operation of law  
shall begin on the date that such order 
or other operation of law takes effect  
and shall end on the date that such     
order or other operation of law expires 
or is otherwise terminated4 ,during any 
such period1 the maximum number of days 
for which a skilled nursing facility may
 deny access to a resident by an        
essential caregiver of the resident is  
#g total days 7or1 subject to the       
approval of the department of health of 
the ,state in which the facility is     
located1 #ad total days74  7v7          

,compliance and notification  7,i7      
,authority ,no essential caregiver who  
upholds the agreement described in      
clause 7vii77,,iii7 shall be denied     
access to the skilled nursing facility  
of the resident involved4  7,,ii7       
,notification ,if an essential caregiver
 fails to comply with an agreement with 
a skilled nursing facility described in 
clause 7vii77,,iii71 the facility must  
first provide a warning to the essential
 caregiver and resident in writing      
citing specific issues of non-compliance
 and providing clear guidance for       
corrective measures4  7,,iii7           
,enforcement ,if an essential caregiver 
or resident1 after receiving a          
notification of noncompliance described 
in subclause 7,,ii71 fails to take      
corrective action1 the essential        
caregiver may subsequently be denied    
access to the resident4 ,in such cases1 
the facility shall provide to such      
caregiver and such resident 7or health  
care proxy of such resident71 not later 

than #bd hours after such denial of     
access occurs1 a written explanation as 
to why such caregiver was denied access 
to such resident4 ,such explanation must
 include the resident's and caregiver's 
options for appeal under the processes  
established under clause 7vi74  7vi7    
,options for residents and caregivers to
 appeal denials of access  7,i7 ,in     
general ,not later than #b years after  
the date of enactment of this           
subparagraph1 the ,secretary shall issue
 a final rule establishing a process for
 residents and caregivers to appeal     
denials of access4  7,,ii7 ,appeals     
process ,the agency responsible for     
overseeing the appeals process          
established under subclause 7,i7 shall--
 7aa7 receive appeals from residents and
 essential caregivers challenging a     
decision by a skilled nursing facility  
to deny access under clause 7v72 and    
7bb7 investigate all such appeals within
 #dh hours of receipt4  7,,iii7 ,burden 
of proof ,during an appeal received     

under the appeals process established   
under subclause 7,i71 if a skilled      
nursing facility defends a decision to  
deny access to an essential caregiver   
under clause 7v7 on the basis that the  
essential caregiver violated the        
agreement described in clause           
7vii77,,iii71 the skilled nursing       
facility shall have the burden of proof 
in demonstrating that the essential     
caregiver violated such agreement4      
7,,iv7 ,resolution of appeal ,with      
respect to an appeal received under the 
appeals process established under       
subclause 7,i71 the agency responsible  
for overseeing the appeal shall make a  
determination as to whether a skilled   
nursing facility violated a requirement 
or prohibition of this subparagraph     
within #dh hours of commencing its      
investigation4 ,if the agency determines
 that a facility has violated such a    
requirement or prohibition the agency   
shall-- 7aa7 require the facility to    
allow immediate access to the essential 

caregiver in question2  7bb7 require the
 facility to establish a corrective     
action plan to prevent the recurrence of
 such violation within a #g-;day period 
of receiving notice from the agency2 and
  7cc7 impose a civil money penalty in  
an amount to be determined by the agency
 7not to exceed #e1jjj7 if such facility
 fails to implement the corrective      
action plan with the #g-;day period     
specified in item 7bb74  7vii7          
,definition of essential caregiver ,for 
purposes of this subparagraph1 the term 
essential caregiver means1 with respect 
to a resident of a skilled nursing      
facility1 an individual who-- 7,i7 is   
designated by or on behalf of the       
resident pursuant to clause 7i7 or      
clause 7ii72  7,,ii7 will provide       
assistance to such resident1 which may  
include assistance with activities of   
daily living or providing emotional     
support or companionship to such        
resident2 and  7,,iii7 agrees to follow 
all safety protocols established by such

 facility1 which shall be clearly       
specified in writing and may be no more 
restrictive than the safety protocols   
7including safety standards and entry   
requirements7 applicable to staff of    
such facility4  4  7b7 ,medicaid nursing
 facilities ,section #aiai7;c77#c7 of   
the ,social ,security ,act 7#db         
,u4,s4,c4 #acifr7c77#c77 is amended--   
7#a7 by redesignating subparagraphs 7,a7
 through 7,e7 as clauses 7i7 through    
7v71 respectively2  7#b7 by striking ,a 
nursing facility must-- and inserting   
the following3  7,a7 ,in general ,a     
nursing facility shall--  2 and  7#c7 by
 adding at the end the following new    
subparagraph3  7,b7 ,access to essential
 caregivers during emergency periods    
when visitation is otherwise restricted 
7i7 ,designation of essential caregiver 
,each nursing facility shall recognize  
the right of each resident of such      
facility to--  7,i7 designate and have  
access to essential caregivers for such 
resident at all times1 including during 

any period of emergency in which regular
 visitation is restricted by order of a 
,federal1 ,state1 or local authority or 
by other operation of law2 and  7,,ii7  
amend such designation at any time4     
7ii7 ,presumption of designation ,for   
purposes of clause 7i71 in the case of a
 resident who is unable1 by reason of   
cognitive or mental disability1 to make 
an election described in such clause1   
the resident representative 7as defined 
in section #dhc4e of title #db1 ,code of
 ,federal ,regulations7 of such resident
 shall be permitted to make such        
designation for such resident4  7iii7   
,access to essential caregivers during  
emergency periods when visitation is    
otherwise restricted ,during a period of
 emergency in which regular visitation  
is restricted by order of a ,federal1   
,state1 or local authority or by other  
operation of law1 including any period  
in which a waiver or modification of    
requirements pursuant to section #aace  
is in effect1 a nursing facility shall--

  7,i7 not deny in-person access to a   
resident by an essential caregiver of   
the resident except as provided in this 
subparagraph2  7,,ii7 allow at least #a 
essential caregiver to have access to   
and provide assistance to such resident 
at such facility every day and at any   
time2 and  7,,iii7 enforce the agreement
 described in clause 7vii77,,iii7 with  
respect to an essential caregiver4  7iv7
 ,restrictions on access  7,i7 ,in      
general ,during a period of emergency in
 which regular visitation is restricted 
by order of a ,federal1 ,state1 or local
 authority or by other operation of law1
 including any period in which a waiver 
or modification of requirements pursuant
 to section #aace is in effect1 a       
nursing facility may deny access to a   
resident by an essential caregiver of   
the resident for--  7aa7 an initial     
period of not longer than #g days2 and  
7bb7 one additional period of not longer
 than #g days 7in addition to the       
initial period described in item 7aa77  

if the department of health of the      
,state in which the facility is located 
approves the denial of access for such  
additional period4  7,,ii7 ,rule of     
application ,for purposes of subclause  
7,i71 a period of emergency in which    
regular visitation is restricted by     
order of a ,federal1 ,state1 or local   
authority or by other operation of law  
shall begin on the date that such order 
or other operation of law takes effect  
and shall end on the date that such     
order or other operation of law expires 
or is otherwise terminated4 ,during any 
such period1 the maximum number of days 
for which a nursing facility may deny   
access to a resident by an essential    
caregiver of the resident is #g total   
days 7or1 subject to the approval of the
 department of health of the ,state in  
which the facility is located1 #ad total
 days74  7v7 ,compliance and            
notification  7,i7 ,authority ,no       
essential caregiver who upholds the     
agreement described in clause           

7vii77,,iii7 shall be denied access to  
the nursing facility of the resident    
involved4  7,,ii7 ,notification ,if an  
essential caregiver fails to comply with
 an agreement with a nursing facility   
described in clause 7vii77,,iii71 the   
facility must first provide a warning to
 the essential caregiver and resident in
 writing citing specific issues of      
non-compliance and providing clear      
guidance for corrective measures4       
7,,iii7 ,enforcement ,if an essential   
caregiver or resident1 after receiving a
 notification of noncompliance described
 in subclause 7,,ii71 fails to take     
corrective action1 the essential        
caregiver may subsequently be denied    
access to the resident4 ,in such cases1 
the facility shall provide to such      
caregiver and such resident 7or health  
care proxy of such resident71 not later 
than #bd hours after such denial of     
access occurs1 a written explanation as 
to why such caregiver was denied access 
to such resident4 ,such explanation must

 include the resident's and caregiver's 
options for appeal under the processes  
established under clause 7vi74  7vi7    
,options for residents and caregivers to
 appeal denials of access  7,i7 ,in     
general ,not later than #b years after  
the date of enactment of this           
subparagraph1 the ,secretary shall issue
 a final rule establishing a process for
 residents and caregivers to appeal     
denials of access4  7,,ii7 ,appeals     
process ,the agency responsible for     
overseeing the appeals process          
established under subclause 7,i7 shall--
  7aa7 receive appeals from residents   
and essential caregivers challenging a  
decision by a nursing facility to deny  
access under clause 7v72 and  7bb7      
investigate all such appeals within #dh 
hours of receipt4  7,,iii7 ,burden of   
proof ,during an appeal received under  
the appeals process established under   
subclause 7,i71 if a nursing facility   
defends a decision to deny access to an 
essential caregiver under clause 7v7 on 

the basis that the essential caregiver  
violated the agreement described in     
clause 7vii77,,iii71 the nursing        
facility shall have the burden of proof 
in demonstrating that the essential     
caregiver violated such agreement4      
7,,iv7 ,resolution of appeal ,with      
respect to an appeal received under the 
appeals process established under       
subclause 7,i71 the agency responsible  
for overseeing the appeal shall make a  
determination as to whether a nursing   
facility violated a requirement or      
prohibition of this subparagraph within 
#dh hours of commencing its             
investigation4 ,if the agency determines
 that a facility has violated such a    
requirement or prohibition the agency   
shall--  7aa7 require the facility to   
allow immediate access to the essential 
caregiver in question2  7bb7 require the
 facility to establish a corrective     
action plan to prevent the recurrence of
 such violation within a #g-;day period 
of receiving notice from the agency2 and

  7cc7 impose a civil money penalty in  
an amount to be determined by the agency
 7not to exceed #e1jjj7 if such facility
 fails to implement the corrective      
action plan with the #g-;day period     
specified in item 7bb74  7vii7          
,definition of essential caregiver ,for 
purposes of this subparagraph1 the term 
essential caregiver means1 with respect 
to a resident of a nursing facility1 an 
individual who--  7,i7 is designated by 
or on behalf of the resident pursuant to
 clause 7i7 or clause 7ii72  7,,ii7 will
 provide assistance to such resident1   
which may include assistance with of    
activities of daily living or providing 
emotional support or companionship to   
such resident2 and  7,,iii7 agrees to   
follow all safety protocols established 
by such facility1 which shall be clearly
 specified in writing and may be no more
 restrictive than the safety protocols  
7including safety standards and entry   
requirements7 applicable to staff of    
such facility4  4  7c7 ,intermediate    

care facilities for the intellectually  
disabled ,section #aije7;d7 of the      
,social ,security ,act 7#db ,u4,s4,c4   
#acif;d7d77 is amended--  7#a7 in       
paragraph 7#b71 by striking and at the  
end2  7#b7 in paragraph 7#c71 by        
striking the period and inserting 2 and2
 and  7#c7 by adding at the end the     
following new paragraph3  7#d7 the      
institution complies with the           
requirements relating to the designation
 of1 and access to residents by1        
essential caregivers described in       
section #aiai7;c77#c77;,b7 in the same  
manner as if such institution were a    
nursing facility4  4  7d7 ,inpatient    
rehabilitation facilities ,section      
#ahff7;a77#a7 of the ,social ,security  
,act 7#db ,u4,s4,c4 #acie;cc7a77#a77 is 
amended-- 7#a7 in subparagraph 7,x71 by 
striking and at the end2  7#b7 in       
subparagraph 7,y71 by striking the      
period at the end and inserting 1 and2  
and  7#c7 by inserting after            
subparagraph 7,y7 the following new     

subparagraph3  7,z7 in the case of an   
inpatient rehabilitation facility that  
is located on the same campus 7as       
defined by the ,secretary7 as a skilled 
nursing facility1 nursing facility 7as  
defined in section #aiai7;a771 or       
intermediate care facility for the      
intellectually disabled 7as described in
 section #aije7;d771 to comply with the 
requirements relating to the designation
 of1 and access to residents by1        
essential caregivers described in       
section #ahai7;c77#c77;,b7 in the same  
manner as if such institution were a    
skilled nursing facility4  4  7e7       
,regulations ,the ,secretary of ,health 
and ,human ,services shall1 after       
consultation with stakeholders          
7including residents1 family members1   
long-term care ombudsmen1 other         
advocates of nursing home residents1 and
 nursing home providers71 promulgate    
regulations to carry out this ,act and  
the amendments made by this ,act4  7f7  
,rules of construction  7#a7 ,no new    

authority for ,state and local officials
 to restrict visitation at nursing      
facilities ,nothing in this section or  
the amendments made by this section     
shall be construed as creating any new  
authority for ,state or local officials 
to restrict visitation at nursing       
facilities4  7#b7 ,no new authority for 
nursing facilities to unilaterally      
restrict visitation ,nothing in this    
section or the amendments made by this  
section shall be construed as creating  
any new authority for a skilled nursing 
facility or nursing facility 7as such   
terms are defined in sections #ahai and 
#aiai of the ,social ,security ,act1    
respectively 7#db ,u4,s4,c4 #acie;i-#c1 
#acifr77 to restrict visitation4  7g7   
,effective date ,the amendments made by 
this ,act shall take effect on the date 
that is #bd months after the date of the
 enactment of this ,act1 and shall apply
 with respect to periods beginning on or
 after such date in which regular       
visitation at nursing facilities is     

restricted by order of a ,federal1      
,state1 or local authority or by other  
operation of law4