,i  #aai? ,,congress  #b;d ,session  ,h4
 ,r4 #hajj  ,,9 ,,! ,,h\se ,,(          
,,repres5tatives  ,m>* #bf1 #bjbf,mr4   
,doggett 7= himself & ,ms4 ,s*ak[sky7   
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 am5d titles ,,xi1 ,,xviii1 
& ,,xix ( ! ,social ,security ,act )    
respect to m9imum /aff+ levels 9 skill$ 
nurs+ facilities & nurs+ facilities "u !
 ,m$ic>e & ,m$icaid programs4  #a4 ,%ort
 title ,?is ,act may be cit$ z ! ,safe  
,/aff+ ,saves ,lives ,act4  #b4 ,m9imum 
/aff+ levels 9 nurs+ facilities & skill$
 nurs+ facilities  7a7 ,e/abli%+ m9imum 
/aff+ levels = regi/]$ nurses 9 nurs+   
facilities & skill$ nurs+ facilities    
7#a7 ,m$ic>e  7,a7 ,9 g5]al ,section    
#ahai7;b77#d7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acie;i-#c7;b77#d77 is  

am5d$--  7i7 9 subp>agraph 7,c7-- 7,i7 9
 ! subp>agraph head+1 by ins]t+ be=e    
#bjbi aft] ,requir$ nurs+ c>e2 &  7,,ii7
 9 clause 7i71 by /rik+ ,except z       
provid$ 9 clause 7ii7 & ins]t+ ,)       
respect to skill$ nurs+ facility s]vices
 furni%$ be=e ,janu>y #a1 #bjbi1 except 
z provid$ 9 clause 7ii72 &  7ii7 by add+
 at ! end ! foll[+ new subp>agraph3     
7,d7 ,requir$ nurs+ c>e beg9n+ 9 #bjbi  
7i7 ,9 g5]al ,subject to clause 7iii71  
beg9n+ ,janu>y #a1 #bjbi1 a skill$ nurs+
 facility-- 7,i7 mu/ provide #bd-;h\r   
lic5s$ nurs+ s]vices :i* are suffici5t  
to meet ! nurs+ ne$s ( its resid5ts2    
7,,ii7 mu/ provide = m9imum nurse /aff+ 
levels ) respect to ea* day2  7,,iii7   
mu/ ensure t1 9 c>ry+ out subclauses    
7,i7 & 7,,ii71 a total m9imum ( #d4a    
h\rs ( nurs+ c>e is provid$ p] resid5t  
p] day1 )--  7aa7 #a4c h\rs ( c>e ( su* 
total m9imum consi/+ ( lic5s$ nurs+     
s]vices1 ) #j4ge h\rs ( su* c>e provid$ 
by a regi/]$ pr(essional nurse & #j4ee  
h\rs ( su* c>e provid$ by a lic5s$      

practical nurse2 &  7bb7 #b4h h\rs ( c>e
 ( su* total m9imum provid$ by a nurse  
aide 7z def9$ 9 p>agraph 7#e77;,f772 &  
7,,iv7 mu/ ensure t a regi/]$           
pr(essional nurse is onsite & available 
to furni% lic5s$ nurs+ s]vices #bd h\rs 
a day1 #g days a week4  7ii7 ,secret>ial
 au?ority to e/abli% high] m9imum nurse 
/aff+ levels ,! ,secret>y may e/abli% & 
require skill$ nurs+ facilities to      
provide = m9imum nurse /aff+ levels t   
are high] ?an ! levels requir$ "u ?is   
subp>agraph4  7iii7 ,waiv]  7,i7 ,9     
g5]al ,subject to ! succe$+ provisions (
 ?is clause1 ! ,secret>y may waive !    
requirem5ts "u clause 7i7 7& su*        
additional requirem5ts z may be e/abli%$
 "u clause 7ii77 ) respect to a skill$  
nurs+ facility = a p]iod ( n m ?an #ahj 
days if-- 7aa7 ! facility demon/rates to
 ! satisfaction ( ! ,secret>y t !       
facility _c reasonably comply ) su*     
requirem5ts2  7bb7 ! facility provides  
to ! ,secret>y su* in=mation z !        
,secret>y det]m9es necess>y to support a

 det]m9ation "u item 7aa71 :i* %all     
include in=mation ) respect to-- 7,,aa7 
work=ce & wage data = ! area 9 :i* !    
facility is locat$2 7,,bb7 additional   
employee b5efits (f]$ by ! facility2    
7,,cc7 ! annual rate ( turnov] ) respect
 to nurs+ /aff at ! facility1           
disaggregat$ by category ( /aff2 &      
7,,dd7 ! facility's demon/rat$ commitm5t
 to hir+ nurs+ /aff2 &  7cc7 ! ,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$4  7,,ii7         
,ineligibility ,! ,secret>y may n grant 
a waiv] "u ?is clause to a skill$ nurs+ 
facility t-- 7aa7 has be5 id5tifi$ "u ! 
special focus facility program "u       
subsection 7f77#h7 z hav+ sub/antially  
fail$ to meet an applicable requirem5t (
 ?is ,act2 or  7bb7 dur+ ! #a-ye> p]iod 
prec$+ a reque/ = su* a waiv]1 0 f\nd to
 h defici5cies t-- 7,,aa7 result$ 9 h>m 

to a resid5t2 or 7,,bb7 imm$iately      
jeop>diz$ ! heal? or safety ( its       
resid5ts4  7,,iii7 ,limitations ,a      
skill$ nurs+ facility may n receive m   
?an #b consecutive waiv]s "u ?is clause4
  7iv7 ,rule ( con/ruction reg>d+ ,/ate 
au?ority to e/abli% high] m9imum nurse  
/aff+ levels ,no?+ 9 ?is subp>agraph may
 be con/ru$ z prev5t+ a ,/ate f e/abli%+
 or requir+ skill$ nurs+ facilities 9 ! 
,/ate to provide = m9imum nurse /aff+   
levels t are high] ?an ! levels requir$ 
"u ?is subp>agraph4  4  7,b7 ,en=cem5t  
7i7 ,increas$ survey frequ5cy ,section  
#ahai7;g77#b77;,a77iii7 ( ! ,social     
,security ,act 7#db ,u4,s4,c4           
#acie;i-#c7;g77#b77;,a77iii77 is am5d$--
  7,i7 9 subclause 7,i71 by /rik+ ,ea* &
 ins]t+ ,subject to subclause 7,,iii71  
ea*2 &  7,,ii7 by add+ at ! end ! foll[+
 new subclause3  7,,iii7 ,/aff+ level   
surveys ,beg9n+ ,janu>y #a1 #bjbi1 9 !  
case ( a skill$ nurs+ facility t is f\nd
 n to meet ! m9imum /aff+ requirem5ts ( 
subsection 7b77#d77;,d7 7includ+ su* a  

facility t has 9 effect a waiv] ( su*   
requirem5ts "u clause 7iii7 ( su*       
subsection71 su* facility %all be       
subject to a /&>d survey n lat] ?an #c  
mon?s aft] ! date ( ! previ\s /&>d      
survey conduct$ "u ?is subp>agraph4  4  
7ii7 ,prohibition on admission ( new    
resid5ts2 audits ,section #ahai7;h7 ( ! 
,social ,security ,act 7#db ,u4,s4,c4   
#acie;i-#c7;h77 is am5d$--  7,i7 9      
p>agraph 7#a71 by /rik+ ,if a ,/ate     
f9ds1 on ! basis ( a /&>d & ins]t+      
,subject to p>agraph 7#g71 if a ,/ate   
f9ds1 on ! basis ( a /&>d2  7,,ii7 9    
p>agraph 7#b71 by /rik+ ,) respect to & 
ins]t+ ,subject to p>agraph 7#g71 )     
respect to2 &  7,,iii7 by add+ at ! end 
! foll[+ new p>agraph3  7#g7 ,special   
rule ) respect to m9imum nurse /aff+    
requirem5ts  7,a7 ,9 g5]al ,beg9n+      
,janu>y #a1 #bjbi1 if a ,/ate f9ds1 on !
 basis ( a /&>d1 ext5d$1 or p>tial      
ext5d$ survey "u subsection 7g77#b7 or  
o!rwise1 t a skill$ nurs+ facility does 
n meet ! m9imum /aff+ requirem5ts (     

subsection 7b77#d77;,d7 7)\t reg>d to   
:e!r su* facility has 9 effect a waiv] (
 su* requirem5ts "u clause 7iii7 ( su*  
subsection71 ! ,/ate %all recomm5d to ! 
,secret>y t ! ,secret>y take su* actions
 z describ$ 9 subp>agraph 7,b74  7,b7   
,secret>ial au?ority ,beg9n+ ,janu>y #a1
 #bjbi1 ) respect to any skill$ nurs+   
facility 9 a ,/ate1 if ! ,secret>y f9ds1
 or pursuant to a recomm5dation ( !     
,/ate "u subp>agraph 7,a7 f9ds1 t a     
skill$ nurs+ facility does n meet !     
m9imum /aff+ requirem5ts ( subsection   
7b77#d77;,d7 7)\t reg>d to :e!r su*     
facility has 9 effect a waiv] ( su*     
requirem5ts "u clause 7iii7 ( su*       
subsection71 ! ,secret>y %all d5y any   
fur!r paym5ts "u ?is title ) respect to 
any individuals entitl$ to b5efits "u   
?is title admitt$ to ! facility = !     
p]iod beg9n+ on ! effective date ( !    
f9d+ & end+ on ! lat] (-- 7i7 ! date t  
is #ahj days aft] su* effective date2 or
  7ii7 ! date on :i* ! ,secret>y        
det]m9es t ! facility has come into     

compliance ) su* m9imum /aff+           
requirem5ts4  7,c7 ,relation%ip to o!r  
en=cem5t me*anisms ,! rem$ies provid$ "u
 ?is p>agraph are 9 addition to ^?      
o!rwise available "u ?is subsection &   
%all n be con/ru$ z limit+ su* o!r      
rem$ies4  4  7iii7 ,ineligibility =     
,,snf ,,vbp ,program ,section           
#ahhh7;h77#a77;,c7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acieyy7h77#a77;,c77 is am5d$-- 7,i7 by 
r$esignat+ clauses 7i7 & 7ii7 z         
subclauses 7,i7 & 7,,ii71 respectively1 
& adju/+ ! m>g9s accord+ly2  7,,ii7 by  
/rik+ ,) respect & ins]t+ ! foll[+3  7i7
 ,9 g5]al ,) respect  2 &  7,,iii7 by   
add+ at ! end ! foll[+ new clause3  7ii7
 ,exclusion ( facilities out (          
compliance ) m9imum /aff+ /&>ds ,)      
respect to paym5ts = s]vices furni%$ on 
or aft] ,janu>y #a1 #bjbi1 ?is          
subsection %all n apply to a facility t 
does n meet ! m9imum /aff+ requirem5ts (
 subsection 7b77#d77;,d7 7includ+ su* a 
facility t has 9 effect a waiv] ( su*   

requirem5ts "u clause 7iii7 ( su*       
subsection74  4  7,c7 ,application to   
transf] & dis*>ge rights ,section       
#ahai7;c77#b77;,a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acie;i-#c7;c77#b77;,a77 is am5d$ by    
add+ at ! end ( ! flu%-left text !      
foll[+ new s5t5ce3 ,beg9n+ ,janu>y #a1  
#bjbi1 a skill$ nurs+ facility may n    
transf] or dis*>ge a resid5t solely =   
purposes ( meet+ ! m9imum /aff+         
requirem5ts "u subsection 7b77#d77;,d744
  7,d7 ,notice ( noncompliance to       
resid5ts & gu>dians  7i7 ,9 g5]al       
,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 ,notice 9 ! case (      
noncompliance ) m9imum /aff+ /&>ds      
,beg9n+ ,janu>y #a1 #bjbi1 9 ! case ( a 
skill$ nurs+ facility t does n meet !   
m9imum /aff+ requirem5ts ( subsection   
7b77#d77;,d7 7includ+ su* a facility t  
has 9 effect a waiv] ( su* requirem5ts  
"u clause 7iii7 ( su* subsection71 su*  

facility %all-- 7,a7 prom95tly display  
at ! entrance to ! facility a notice t  
su* facility does n meet su* /&>ds 7&   
has 9 effect su* a waiv]1 if            
applicable72 &  7,b7 provide ea* resid5t
 ( ! facility 7or1 :]e appropriate1 !   
gu>dians or legal repres5tatives ( su*  
resid5ts7 & memb]s ( _! imm$iate        
families ) a writt5 copy ( su* notice4  
4  7ii7 ,nurs+ ,home ,comp>e website    
,section #ahai7;i77#a77;,a77i7 ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#acie;i-#c7;i77#a77;,a77i77 is am5d$ by 
ins]t+ 7&1 beg9n+ ,janu>y #a1 #bjbi1    
in=mation on :e!r ! facility meets !    
m9imum /aff+ requirem5ts ( subsection   
7b77#d77;,d7 7or has 9 effect a waiv] ( 
su* requirem5ts "u clause 7iii7 ( su*   
subsection7 aft] /aff+ turnov] & t5ure4 
7,e7 ,con=m+ am5dm5t ,section           
#ahai7;f77#b77;,b77iii77,i77a7 ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#acie;i-#c7;f77#b77;,b77iii77,i77a77 is 
am5d$ by ins]t+ or subsection           
7b77#d77;,d77iii7 aft] subsection       

7b77#d77;,c77ii77,,ii74  7#b7 ,m$icaid  
7,a7 ,9 g5]al ,section #aiai7;b77#d7 ( !
 ,social ,security ,act 7#db ,u4,s4,c4  
#acifr7b77#d77 is am5d$--  7i7 9        
subp>agraph 7,c77i7-- 7,i7 9 ! clause   
head+1 by ins]t+ be=e #bjbi aft] ,g5]al 
requirem5ts2 &  7,,ii7 9 ! matt] prec$+ 
subclause 7,i71 by ins]t+ & be=e ,janu>y
 #a1 #bjbi1 aft] ,) respect to nurs+    
facility s]vices provid$ on or aft]     
,octob] #a1 #aiij12 &  7ii7 by add+ at !
 end ! foll[+ new subp>agraph3  7,d7    
,g5]al requirem5ts beg9n+ 9 #bjbi  7i7  
,9 g5]al ,subject to clause 7iii71      
beg9n+ ,janu>y #a1 #bjbi1 a nurs+       
facility-- 7,i7 mu/ provide #bd-;h\r    
lic5s$ nurs+ s]vices :i* are suffici5t  
to meet ! nurs+ ne$s ( its resid5ts2    
7,,ii7 mu/ provide = m9imum nurse /aff+ 
levels ) respect to ea* day2  7,,iii7   
mu/ ensure t1 9 c>ry+ out subclauses    
7,i7 & 7,,ii71 a total m9imum ( #d4a    
h\rs ( nurs+ c>e is provid$ p] resid5t  
p] day1 )--  7aa7 #a4c h\rs ( c>e ( su* 
total m9imum consi/+ ( lic5s$ nurs+     

s]vices1 ) #j4ge h\rs ( su* c>e provid$ 
by a regi/]$ pr(essional nurse & #j4ee  
h\rs ( su* c>e provid$ by a lic5s$      
practical nurse2 &  7bb7 #b4h h\rs ( c>e
 ( su* total m9imum provid$ by a nurse  
aide 7z def9$ 9 p>agraph 7#e77;,f772 &  
7,,iv7 mu/ ensure t a regi/]$           
pr(essional nurse is onsite & available 
to furni% lic5s$ nurs+ s]vices #bd h\rs 
a day1 #g days a week4  7ii7 ,secret>ial
 au?ority to e/abli% high] m9imum nurse 
/aff+ levels ,! ,secret>y may e/abli% & 
require nurs+ facilities to provide =   
m9imum nurse /aff+ levels t are high]   
?an ! levels requir$ "u ?is subp>agraph4
  7iii7 ,waiv]  7,i7 ,9 g5]al ,subject  
to ! succe$+ provisions ( ?is clause1 a 
,/ate may waive ! requirem5ts "u clause 
7i7 7& su* additional requirem5ts z may 
be e/abli%$ "u clause 7ii77 ) respect to
 a nurs+ facility = a p]iod ( n m ?an   
#ahj days if-- 7aa7 ! facility          
demon/rates to ! satisfaction ( ! ,/ate 
t ! facility _c reasonably comply ) su* 
requirem5ts2  7bb7 ! facility provides  

to ! ,/ate su* in=mation z ! ,/ate      
det]m9es necess>y to support a          
det]m9ation "u item 7aa71 :i* %all      
include in=mation ) respect to-- 7,,aa7 
work=ce & wage data = ! area 9 :i* !    
facility is locat$2 7,,bb7 additional   
employee b5efits (f]$ by ! facility2    
7,,cc7 ! annual rate ( turnov] ) respect
 to nurs+ /aff at ! facility1           
disaggregat$ by category ( /aff2 &      
7,,dd7 ! facility's demon/rat$ commitm5t
 to hir+ nurs+ /aff2 &  7cc7 ! ,/ate    
ag5cy grant+ a waiv] ( su* requirem5ts  
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$4  ,a waiv] "u ?is
 clause %all be subject to ! review ( ! 
,secret>y & subject to clause 7iv7 %all 
be accept$ 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]sonnel4  7,,ii7 ,ineligibility ,!     
,/ate may n grant a waiv] "u ?is clause 
to a skill$ nurs+ facility t-- 7aa7 has 
be5 id5tifi$ "u ! special focus facility
 program "u subsection 7f77#aj7 z hav+  
sub/antially fail$ to meet applicable   
requirem5ts ( ?is ,act2 or  7bb7 dur+ ! 
#a-ye> p]iod prec$+ a reque/ = su* a    
waiv]1 0 f\nd to h defici5cies t--      
7,,aa7 result$ 9 h>m to a resid5t2 or   
7,,bb7 imm$iately jeop>diz$ ! heal? or  
safety ( its resid5ts4  7,,iii7         
,limitations ,a nurs+ facility may n    
receive m ?an #b consecutive waiv]s "u  
?is clause4  7iv7 ,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+ requirem5ts1 ! ,secret>y %all     
assume & ex]cise ! au?ority ( ! ,/ate to
 grant waiv]s4  7v7 ,rule ( con/ruction 
reg>d+ ,/ate au?ority to e/abli% high]  
m9imum nurse /aff+ levels ,no?+ 9 ?is   

subp>agraph may be con/ru$ z prev5t+ a  
,/ate f e/abli%+ or requir+ skill$ nurs+
 facilities 9 ! ,/ate to provide =      
m9imum nurse /aff+ levels t are high]   
?an ! levels requir$ "u ?is subp>agraph4
  4  7,b7 ,en=cem5t  7i7 ,increas$      
survey frequ5cy ,section                
#aiai7;g77#b77;,a77iii7 ( ! ,social     
,security ,act 7#db ,u4,s4,c4           
#acifr7g77#b77;,a77iii77 is am5d$-- 7,i7
 9 subclause 7,i71 by /rik+ ,ea* &      
ins]t+ ,subject to subclause 7,,iii71   
ea*2 &  7,,ii7 by add+ at ! end ! foll[+
 new subclause3  7,,iii7 ,/aff+ level   
surveys ,beg9n+ ,janu>y #a1 #bjbi1 9 !  
case ( a nurs+ facility t is f\nd n to  
meet ! m9imum /aff+ requirem5ts (       
subsection 7b77#d77;,d7 7includ+ su* a  
facility t has 9 effect a waiv] ( su*   
requirem5ts "u clause 7iii7 ( su*       
subsection71 su* facility %all be       
subject to a /&>d survey n lat] ?an #c  
mon?s aft] ! date ( ! previ\s /&>d      
survey conduct$ "u ?is subp>agraph4  4  
7ii7 ,prohibition on admission ( new    

resid5t2 audits ,section #aiai7;h7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#acifr7h77 is am5d$-- 7,i7 9 p>agraph   
7#a71 by /rik+ ,if a ,/ate f9ds1 on !   
basis ( a /&>d & ins]t+ ,subject to     
p>agraph 7#aj71 if a ,/ate f9ds1 on !   
basis ( a /&>d2  7,,ii7 9 p>agraph      
7#b7-- 7aa7 9 subp>agraph 7,c71 by /rik+
 ,if a nurs+ facility & ins]t+ ,subject 
to p>agraph 7#aj71 if a nurs+ facility2 
&  7bb7 9 subp>agraph 7,d71 by /rik+ ,9 
! case ( & ins]t+ ,subject to p>agraph  
7#aj71 9 ! case (2  7,,iii7 9 p>agraph  
7#c7--  7aa7 9 subp>agraph 7,a71 by     
ins]t+ be=e ! p]iod ! foll[+3 & !       
rem$ies describ$ 9 p>agraph 7#aj77;,b72 
&  7bb7 9 subp>agraph 7,b71 by /rik+ ,) 
respect to & ins]t+ ,subject to p>agraph
 7#aj71 ) respect to2 &  7,,iv7 by add+ 
at ! end ! foll[+ new p>agraph3  7#aj7  
,special rule ) respect to m9imum nurse 
/aff+ requirem5ts  7,a7 ,9 g5]al ,beg9n+
 ,janu>y #a1 #bjbi1 if a ,/ate f9ds1 on 
! basis ( a /&>d1 ext5d$1 or p>tial     
ext5d$ survey "u subsection 7g77#b7 or  

o!rwise1 t a nurs+ facility does n meet 
! m9imum /aff+ requirem5ts ( subsection 
7b77#d77;,d7 7)\t reg>d to :e!r su*     
facility has 9 effect a waiv] ( su*     
requirem5ts "u clause 7iii7 ( su*       
subsection71 ! ,/ate %all--  7i7 d5y any
 fur!r paym5ts "u ! ,/ate plan ) respect
 to all individuals enroll$ "u su* plan 
:o are admitt$ to ! facility aft] !     
effective date ( ! f9d+2 &  7ii7        
recomm5d to ! ,secret>y t ! ,secret>y   
take su* actions z describ$ 9           
subp>agraph 7,b74  7,b7 ,secret>ial     
au?ority ,beg9n+ ,janu>y #a1 #bjbi1 )   
respect to any nurs+ facility 9 a ,/ate 
o!r ?an a ,/ate nurs+ facility1 if !    
,secret>y f9ds1 or pursuant to a        
recomm5dation ( ! ,/ate "u subp>agraph  
7,a7 f9ds1 t a skill$ nurs+ facility    
does n meet ! m9imum /aff+ requirem5ts (
 subsection 7b77#d77;,d7 7)\t reg>d to  
:e!r su* facility has 9 effect a waiv] (
 su* requirem5ts "u clause 7iii7 ( su*  
subsection71 ! ,secret>y %all d5y any   
fur!r paym5ts to ! ,/ate = m$ical       

assi/ance furni%$ by ! facility to any  
individual admitt$ to ! facility = !    
p]iod beg9n+ on ! effective date ( !    
f9d+ & end+ on ! lat] (-- 7i7 ! date t  
is #ahj days aft] su* effective date2 or
  7ii7 ! date on :i* ! ,secret>y        
det]m9es t ! facility has come into     
compliance ) su* m9imum /aff+           
requirem5ts4  7,c7 ,relation%ip to o!r  
en=cem5t me*anisms ,! rem$ies provid$ "u
 ?is p>agraph are 9 addition to ^?      
o!rwise available "u ?is subsection &   
%all n be con/ru$ z limit+ su* o!r      
rem$ies4  4  7iii7  ,ineligibility =    
c]ta9 ,/ate direct$ paym5ts  ,!         
,secret>y ( ,heal? & ,human ,s]vices    
%all revise section #dch4f7;c77#b7 (    
title #db1 ,code ( ,f$]al ,regulations  
7or a successor regulation71 su* t1     
beg9n+ ,janu>y #a1 #bjbi1 no ,/ate      
direct$ paym5t specifi$ 9 su* section   
may be made = nurs+ facility s]vices    
furni%$ by a facility t does n meet !   
m9imum /aff+ requirem5ts ( subp>agraph  
7,d7 ( section #aiai7;b77#d7 ( ! ,social

 ,security ,act 7#db ,u4,s4,c4          
#acifr7b77#d771 z add$ by subp>agraph   
7,a7 7includ+ su* a facility t has 9    
effect a waiv] ( su* requirem5ts "u     
clause 7iii7 ( su* subp>agraph74  7iv7  
,application to transf] & dis*>ge rights
 ,section #aiai7;c77#b77;,a7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#acifr7c77#b77;,a77 is am5d$ by add+ at 
! end ( ! flu%-left text ! foll[+ new   
s5t5ce3 ,beg9n+ ,janu>y #a1 #bjbi1 a    
nurs+ facility may n transf] or dis*>ge 
a resid5t solely = purposes ( meet+ !   
m9imum /aff+ requirem5ts "u subsection  
7b77#d77;,d744  7v7 ,notice (           
noncompliance to resid5ts & gu>dians    
7,i7 ,9 g5]al ,section #aiai7;c7 ( !    
,social ,security ,act 7#db ,u4,s4,c4   
#acifr7c77 is am5d$ by add+ at ! end !  
foll[+ new p>agraph3  7#i7 ,notice 9 !  
case ( noncompliance ) m9imum /aff+     
/&>ds ,beg9n+ ,janu>y #a1 #bjbi1 9 !    
case ( a nurs+ facility t does n meet ! 
m9imum /aff+ requirem5ts ( subsection   
7b77#d77;,d7 7includ+ su* a facility t  

has 9 effect a waiv] ( su* requirem5ts  
"u clause 7iii7 ( su* subsection71 su*  
facility %all-- 7,a7 prom95tly display  
at ! entrance to ! facility a notice t  
su* facility does n meet su* /&>ds 7&   
has 9 effect su* a waiv]1 if            
applicable72 &  7,b7 provide ea* resid5t
 ( ! facility 7or1 :]e appropriate1 !   
gu>dians or legal repres5tatives ( su*  
resid5ts7 & memb]s ( _! imm$iate        
families ) a writt5 copy ( su* notice4  
4  7,,ii7 ,nurs+ ,home ,comp>e website  
,section #aiai7;i77#a77;,a77i7 ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#acifr7i77#a77;,a77i77 is am5d$ by      
ins]t+ 7&1 beg9n+ ,janu>y #a1 #bjbi1    
in=mation on :e!r ! facility meets !    
m9imum /aff+ requirem5ts ( subsection   
7b77#d77;,d7 7or has 9 effect a waiv] ( 
su* requirem5ts "u clause 7iii7 ( su*   
subsection7 aft] /aff+ turnov] & t5ure4 
7,c7 ,con=m+ am5dm5ts  7i7 ,item 7a7 (  
section #aiai7;f77#b77;,b77iii77,i7 ( ! 
,social ,security ,act 7#db ,u4,s4,c4   
#acifr7f77#b77;,b77iii77,i77 is am5d$ by

 ins]t+ or subsection 7b77#d77;,d77iii7 
aft] subsection 7b77#d77;,c77ii74  7ii7 
,p>agraph 7#i7 ( section #aiai7;f7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#acifr7f77 is am5d$ by ins]t+ or        
subsection 7b77#d77;,d77iii7 aft]       
subsection 7b77#d77;,c77ii74  7b7       
,inclusion ( time/amp on facility /aff+ 
data ,section #aabh;,i7g7 ( ! ,social   
,security ,act 7#db ,u4,s4,c4           
#acbj;a-#g;j7g77 is am5d$-- 7#a7 9      
p>agraph 7#c71 by /rik+ & at ! end2     
7#b7 9 p>agraph 7#d71 by /rik+ ! p]iod  
at ! end & ins]t+ 2 &2 &  7#c7 by ins]t+
 aft] p>agraph 7#d7 ! foll[+ new        
p>agraph3  7#e7 beg9n+ ,janu>y #a1      
#bjbg1 include "t-/amp$ in=mation on !  
h\rs work$ p] day by ea* c]tifi$        
employee 9 ea* category ( c]tifi$       
employees ref]5c$ 9 p>agraph 7#a74  4   
7c7 ,reports ,section #aabh;,i ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#acbj;a-#g;j7 is am5d$ by add+ at ! end 
! foll[+ new subsection3  7i7 ,reports  
on facility /aff+ levels ,n lat] ?an    

,janu>y #a1 #bjcd1 & e #e ye>s !reaft]1 
! ,secret>y ( ,heal? & ,human ,s]vices  
%all submit to ,congress a report on !  
m9imum nurse /aff+ levels requir$ "u    
sections #ahai7;b77#d77;,d7 &           
#aiai7;b77#d77;,d74 ,ea* su* report %all
 include-- 7#a7 an analysis ( ! impact (
 su* m9imum nurse /aff+ levels on--     
7,a7 resid5t safety2  7,b7 quality (    
c>e2  7,c7 ! rate ( defici5cy citations 
receiv$ by facilities2 &  7,d7 wages1   
b5efits1 & employm5t ret5tion ( nurse   
/aff2 &  7#b7 recomm5dations z to :e!r  
su* m9imum nurse /aff+ levels %\ld be   
adju/$4  4