Nursing Home Improvement and Accountability Act of 2021
This bill establishes reporting, staffing, and other quality control requirements for Medicare skilled nursing facilities and Medicaid nursing facilities.
For example, the bill requires facilities to have registered professional nurses available 24-7 and to provide infection control services overseen by infection preventionists at least 40 hours per week. It also establishes civil penalties for facilities that submit inaccurate reports relating to staffing data and prohibits facilities from entering into pre-dispute arbitration agreements.
Additionally, the Centers for Medicare & Medicaid Services (CMS) must conduct additional quality control and oversight, including (1) auditing facility cost reports; (2) reviewing the quality and effectiveness of compliance surveys; and (3) establishing on-site educational programming for facilities that fail to meet applicable standards. The CMS must also establish minimum staff-to-resident ratios for nursing staff, as it determines appropriate.
The bill also establishes a demonstration program to evaluate the impact of certain changes to facility design, staffing, and care coordination on the health outcomes of residents in skilled nursing facilities. Among other requirements, selected facilities must serve between 5 and 14 residents, offer private rooms, and have resident and family councils.
To improve care furnished and to support the workforce in skilled 
nursing facilities under the Medicare program and in nursing facilities 
          under the Medicaid program, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Nursing Home Improvement and 
Accountability Act of 2021''.

                TITLE I--TRANSPARENCY AND ACCOUNTABILITY

SEC. 101. IMPROVING THE ACCURACY AND RELIABILITY OF CERTAIN SKILLED 
              NURSING FACILITY DATA.

    (a) Reduction in Payments for Inaccurate Reporting.--Section 
1888(e)(6)(A) of the Social Security Act (42 U.S.C. 1395yy(e)(6)(A)) is 
amended--
            (1) in the header, by striking ``for failure to report''; 
        and
            (2) in clause (i)--
                    (A) by striking ``For fiscal years'' and inserting 
                the following:
                                    ``(I) Failure to report.--For 
                                fiscal years''; and
                    (B) by adding at the end the following new 
                subclause:
                                    ``(II) Reporting of inaccurate 
                                information.--For fiscal years 
                                beginning with fiscal year 2025, in the 
                                case of a skilled nursing facility that 
                                submits data under this paragraph, 
                                measures under subsection (h), or 
                                resident assessment data described in 
                                section 1819(b)(3) with respect to such 
                                fiscal year that is inaccurate (as 
                                determined by the Secretary through the 
                                validation process described in section 
                                1888(h)(12) or otherwise), after 
                                determining the percentage described in 
                                paragraph (5)(B)(i), and after 
                                application of clauses (ii) and (iii) 
                                of paragraph (5)(B) and of subclause 
                                (I) if this clause (if applicable), the 
                                Secretary shall reduce such percentage 
                                for payment rates during such fiscal 
                                year by 2 percentage points.''.
    (b) Data and Measures Validation.--Section 1888(h)(12) of the 
Social Security Act (42 U.S.C. 1395yy(h)(12)) is amended--
            (1) in subparagraph (A), by striking ``and the data 
        submitted under subsection (e)(6)'' and inserting ``, the data 
        submitted under subsection (e)(6), and, beginning with fiscal 
        year 2024, the resident assessment data described in section 
        1819(b)(3)'';
            (2) in subparagraph (B), by striking ``of $5,000,000'' and 
        all that follows through the period at the end and inserting 
        the following: ``of--
                            ``(i) $5,000,000 for each of fiscal years 
                        2023 through 2025; and
                            ``(ii) $50,000,000 for the period of fiscal 
                        years 2026 through 2035;
                to the Centers for Medicare & Medicaid Services Program 
                Management Account, to remain available until 
                expended.''.
    (c) Providing Authority To Collect Data on Additional Measures.--
Section 1888(e)(6)(B)(i)(II) of the Social Security Act (42 U.S.C. 
1395yy(e)(6)(B)(i)(II)) is amended by inserting ``, and data on any 
other validated measure specified by the Secretary'' after ``under such 
subsection (d)(1)''.

SEC. 102. ENSURING ACCURATE INFORMATION ON COST REPORTS.

    Section 1888(f) of the Social Security Act (42 U.S.C. 1395yy(f)) is 
amended by adding at the end the following new paragraphs:
            ``(5) Audit of cost reports.--
                    ``(A) In general.--Beginning in 2022, and annually 
                thereafter, the Secretary shall conduct an audit of 
                cost reports submitted under this title for a 
                representative sample of skilled nursing facilities.
                    ``(B) Funding.--The Secretary shall provide for the 
                transfer, from the Federal Hospital Insurance Trust 
                Fund under section 1817 to the Centers for Medicare & 
                Medicaid Services Program Management Account, of 
                $250,000,000 for fiscal year 2023 for purposes of 
                carrying out this paragraph. Amounts transferred 
                pursuant to the previous sentence shall remain 
                available until expended.
            ``(6) Review of relationship between cost report data and 
        quality.--
                    ``(A) In general.--Not later than 2 years after the 
                Secretary completes the first audit described in 
                paragraph (5), and not less frequently than once every 
                2 years thereafter, the Inspector General of the 
                Department of Health and Human Services shall conduct 
                an analysis of, and submit to Congress a report on, the 
                relationship between skilled nursing facility 
                expenditures for functional accounts described in 
                paragraph (3) and skilled nursing facility quality (as 
                specified by the Inspector General).
                    ``(B) Funding.--The Secretary shall provide for the 
                transfer, from the Federal Hospital Insurance Trust 
                Fund under section 1817 to the Inspector General of the 
                Department of Health and Human Services $25,000,000 for 
                fiscal year 2023 for purposes of carrying out this 
                paragraph. Amounts transferred pursuant to the previous 
                sentence shall remain available until expended.''.

SEC. 103. REQUIRING A SURETY BOND FOR SKILLED NURSING FACILITIES.

    (a) Medicare.--Section 1819(a) of the Social Security Act (42 
U.S.C. 1395i-3(a)) is amended--
            (1) in paragraph (2), by striking ``and'' at the end;
            (2) in paragraph (3), by striking the period and inserting 
        ``; and''; and
            (3) by adding at the end the following new paragraph:
            ``(4) provides the Secretary with a surety bond in a form 
        specified by the Secretary and in an amount that is not less 
        than the minimum of $500,000, unless the Secretary waives the 
        provision of such surety bond due to such facility providing a 
        comparable surety bond under State law.''.
    (b) Medicaid.--Section 1919(a) of the Social Security Act (42 
U.S.C. 1396r(a)) is amended--
            (1) in paragraph (2), by striking ``and'' at the end;
            (2) in paragraph (3), by striking the period and inserting 
        ``; and''; and
            (3) by inserting after paragraph (3) the following new 
        paragraph:
            ``(4) provides the Secretary with a surety bond in a form 
        specified by the Secretary and in an amount that is not less 
        than the minimum of $500,000, unless the Secretary waives the 
        provision of such surety bond due to such facility providing a 
        comparable surety bond under State law.''.

SEC. 104. SURVEY IMPROVEMENTS.

    (a) In General.--Section 1128I of the Social Security Act (42 
U.S.C. 1320a-7j) is amended--
            (1) in the section heading, by striking ``accountability 
        requirements for'' and inserting ``additional requirements with 
        respect to''; and
            (2) by adding at the end the following new subsection:
    ``(i) Survey Improvements.--
            ``(1) Review.--The Secretary shall review (and, as 
        appropriate, identify plans to improve) the following:
                    ``(A) The extent to which surveys conducted under 
                subsection (g) of sections 1819 and 1919 and the 
                enforcement process under subsection (h) of sections 
                1819 and 1919 result in increased compliance with 
                requirements under sections 1819 and 1919 and subpart B 
                of part 483 of title 42, Code of Federal Regulations, 
                with respect to facilities.
                    ``(B) The timeliness and thoroughness of State 
                agency verification of deficiency corrections at 
                facilities.
                    ``(C) The appropriateness of the scoping and 
                substantiation of cited deficiencies at facilities.
                    ``(D) The accuracy of the identification and 
                appropriateness of the scoping of life safety, 
                infection control, and emergency preparedness 
                deficiencies at facilities.
                    ``(E) The timeliness of State agency investigations 
                of--
                            ``(i) complaints at facilities; and
                            ``(ii) reported allegations of abuse, 
                        neglect, and exploitation at facilities.
                    ``(F) The consistency of facility reporting of 
                substantiated complaints to law enforcement.
                    ``(G) The ability of the State agency to 
                sufficiently hire, train, and retain individuals who 
                conduct surveys.
                    ``(H) Any other area related to surveys of 
                facilities, or the individuals conducting such surveys, 
                determined appropriate by the Secretary.
            ``(2) Report.--Not later than 3 years after the date of 
        enactment of this subsection, the Secretary shall submit to 
        Congress a report on the review conducted under paragraph (1), 
        together with recommendations for such legislation and 
        administrative action as the Secretary determines to be 
        appropriate.
            ``(3) Support.--If determined appropriate by the Secretary, 
        based on the review under paragraph (1), the Secretary shall 
        provide training, tools, technical assistance, and financial 
        support to State agencies that perform surveys of facilities 
        for the purpose of improving the surveys conducted under 
        subsection (g) and the enforcement process under subsection (h) 
        with respect to the areas reviewed under paragraph (1).
            ``(4) Funding.--There is appropriated to the Secretary, out 
        of any monies in the Treasury not otherwise appropriated, 
        $570,000,000, to remain available until expended, for purposes 
        of carrying out this subsection.''.

SEC. 105. PROHIBITING PRE-DISPUTE ARBITRATION AGREEMENTS.

    (a) Medicare.--Section 1819(c) of the Social Security Act (42 
U.S.C. 1395i-3(c)) is amended by adding at the end the following new 
paragraph:
            ``(7) Prohibition on use of pre-dispute arbitration 
        agreements.--
                    ``(A) In general.--A skilled nursing facility may 
                not enter into a pre-dispute arbitration agreement with 
                an individual applying to reside or residing in the 
                facility (or a legal representative of such resident), 
                and may not enter into an agreement for services with 
                an entity or individual that enters into a pre-dispute 
                arbitration agreement with an individual applying to 
                reside or residing in the facility (or a legal 
                representative of such resident).
                    ``(B) No validity or enforcement.--A skilled 
                nursing facility shall not enforce a pre-dispute 
                arbitration agreement against a resident or former 
                resident of a skilled nursing facility (or a legal 
                representative of such resident), without regard to 
                whether the agreement was made prior to or after the 
                effective date of this paragraph.
                    ``(C) Definition of pre-dispute arbitration 
                agreement.--In this paragraph, the term `pre-dispute 
                arbitration agreement' means any agreement to arbitrate 
                a potential dispute that, as of the date on which such 
                agreement is entered into, has not yet arisen.
                    ``(D) Judicial review.--A determination as to 
                whether and how this paragraph applies to a pre-dispute 
                arbitration agreement shall be determined under Federal 
                law by a court of competent jurisdiction, rather than 
                an arbitrator, without regard to whether the party 
                opposing arbitration challenges such agreement 
                specifically or in conjunction with any other term of 
                the contract containing such agreement.''.
    (b) Medicaid.--
            (1) Home and community-based services and home health care 
        services.--Section 1915 of the Social Security Act (42 U.S.C. 
        1396n) is amended by adding at the end the following new 
        subsection:
    ``(l) Prohibiting Pre-Dispute Arbitration Agreements.--
            ``(1) In general.--For home and community-based services or 
        home health care services provided under a waiver under this 
        section, section 1902(a)(10)(D), or any other provision 
        authorizing the provision of home and community-based services 
        or home health care services under this title, the provider of 
        such services (and any employee, agent, related entity, or 
        affiliate of such provider) may not enter into a pre-dispute 
        arbitration agreement with an individual receiving such 
        services (or a legal representative of such individual). A 
        provider of such services (and any employee, agent, related 
        entity, or affiliate of such provider) shall not enforce a pre-
        dispute arbitration agreement against an individual receiving 
        such services, or who formerly received such services (or a 
        legal representative of such individual), without regard to 
        whether such agreement was made prior to the effective date of 
        this subsection.
            ``(2) Definition of pre-dispute arbitration agreement.--In 
        this subsection, the term `pre-dispute arbitration agreement' 
        means any agreement to arbitrate a potential dispute that, as 
        of the date on which such agreement is entered into, has not 
        yet arisen.
            ``(3) Judicial review.--A determination as to whether and 
        how this subsection applies to a pre-dispute arbitration 
        agreement shall be determined under Federal law by a court of 
        competent jurisdiction, rather than an arbitrator, without 
        regard to whether the party opposing arbitration challenges 
        such agreement specifically or in conjunction with any other 
        term of the contract containing such agreement.''.
            (2) Nursing facilities.--Section 1919(c) of the Social 
        Security Act (42 U.S.C. 1396r(c)) is amended by adding at the 
        end the following new paragraph:
            ``(9) Prohibition on use of pre-dispute arbitration 
        agreements.--
                    ``(A) In general.--A nursing facility may not enter 
                into a pre-dispute arbitration agreement with an 
                individual applying to reside or residing in the 
                facility (or a legal representative of such resident), 
                and may not enter into an agreement for services with 
                an entity or individual that enters into a pre-dispute 
                arbitration agreement with an individual applying to 
                reside or residing in the facility (or a legal 
                representative of such resident).
                    ``(B) No validity or enforcement.--A nursing 
                facility shall not enforce a pre-dispute arbitration 
                agreement against a resident or former resident of a 
                nursing facility (or a legal representative of such 
                resident), without regard to whether the agreement was 
                made prior to or after the effective date of this 
                paragraph.
                    ``(C) Definition of pre-dispute arbitration 
                agreement.--In this paragraph, the term `pre-dispute 
                arbitration agreement' means any agreement to arbitrate 
                a potential dispute that, as of the date on which such 
                agreement is entered into, has not yet arisen.
                    ``(D) Judicial review.--A determination as to 
                whether and how this paragraph applies to a pre-dispute 
                arbitration agreement shall be determined under Federal 
                law by a court of competent jurisdiction, rather than 
                an arbitrator, without regard to whether the party 
                opposing arbitration challenges such agreement 
                specifically or in conjunction with any other term of 
                the contract containing such agreement.''.

SEC. 106. IMPROVEMENTS TO THE SPECIAL FOCUS FACILITY PROGRAM.

    (a) Appropriate Participation.--
            (1) Medicare.--Section 1819(f)(8) of the Social Security 
        Act (42 U.S.C. 1395i-3(f)(8)) is amended--
                    (A) in subparagraph (A), by striking ``The 
                Secretary'' and inserting ``Subject to the succeeding 
                provisions of this subsection, the Secretary''; and
                    (B) by adding at the end the following new 
                subparagraph:
                    ``(C) Appropriate participation.--Not later than 
                October 1, 2022, the Secretary shall ensure that the 
                number of facilities participating in the special focus 
                facility program is not less than 5 percent of all 
                skilled nursing facilities.''.
            (2) Medicaid.--Section 1919(f)(10) of the Social Security 
        Act (42 U.S.C. 1395r(f)(10)) is amended--
                    (A) in subparagraph (A), by striking ``The 
                Secretary'' and inserting ``Subject to the succeeding 
                provisions of this subsection, the Secretary''; and
                    (B) by adding at the end the following new 
                subparagraph:
                    ``(C) Appropriate participation.--Not later than 
                October 1, 2022, the Secretary shall ensure that the 
                number of facilities participating in the special focus 
                facility program is not less than 5 percent of all 
                nursing facilities.''.
    (b) Compliance Assistance Programs.--
            (1) Medicare.--Section 1819(f)(8) of the Social Security 
        Act (42 U.S.C. 1395i-3(f)(8)), as amended by subsection (a)(1), 
        is amended by adding at the end the following new subparagraph:
                    ``(D) Compliance assistance programs.--
                            ``(i) On-site consultation and educational 
                        programming.--
                                    ``(I) In general.--The Secretary 
                                shall establish on-site consultation 
                                and educational programming for skilled 
                                nursing facilities participating in the 
                                special focus facility program with 
                                respect to compliance with the 
                                applicable requirements under this Act.
                                    ``(II) Entity.--The on-site 
                                consultation and educational 
                                programming described in subclause (I) 
                                shall be carried out by quality 
                                improvement organizations under part B 
                                of title XI or other independent 
                                organizations of a similar type that do 
                                not have conflicts of interest and are 
                                deemed appropriate by the Secretary.
                                    ``(III) Required participation.--A 
                                skilled nursing facility participating 
                                in the special focus facility program 
                                shall participate in any consultations 
                                and educational programming described 
                                in subclause (I) conducted at the 
                                facility.
                            ``(ii) Consultation independent of 
                        enforcement.--
                                    ``(I) In general.--Subject to 
                                subclause (II), on-site consultations 
                                and educational programming described 
                                in clause (i) shall be conducted 
                                independently of any enforcement 
                                activity.
                                    ``(II) Exception.--Subclause (I) 
                                shall not apply in the case where a 
                                triggering event at the skilled nursing 
                                facility is observed in the course of 
                                providing on-site consultations and 
                                educational programming described in 
                                clause (i). In establishing such on-
                                site consultations and educational 
                                programming, the Secretary shall 
                                determine the triggering events for 
                                which the use of necessary enforcement 
                                actions is permitted notwithstanding 
                                the limitation under subclause (I). 
                                Such triggering events shall include 
                                events that are required to be reported 
                                under State and Federal law and a 
                                pattern of deficiencies or problems 
                                that the quality improvement 
                                organization or other organization has 
                                identified for correction but which are 
                                consistently not corrected.''.
            (2) Medicaid.--Section 1919(f)(10) of the Social Security 
        Act (42 U.S.C. 1395r(f)(10)), as amended by subsection (a)(2), 
        is amended by adding at the end the following new subsection:
                    ``(D) Compliance assistance programs.--
                            ``(i) On-site consultation and educational 
                        programming.--
                                    ``(I) In general.--The Secretary 
                                shall establish on-site consultation 
                                and educational programming for nursing 
                                facilities participating in the special 
                                focus facility program with respect to 
                                compliance with the applicable 
                                requirements under this Act.
                                    ``(II) Entity.--The on-site 
                                consultation and educational 
                                programming described in subclause (I) 
                                shall be carried out by quality 
                                improvement organizations under part B 
                                of title XI or other independent 
                                organizations of a similar type that do 
                                not have conflicts of interest and are 
                                deemed appropriate by the Secretary.
                                    ``(III) Required participation.--A 
                                nursing facility participating in the 
                                special focus facility program shall 
                                participate in any consultations and 
                                educational programming described in 
                                subclause (I) conducted at the 
                                facility.
                            ``(ii) Consultation independent of 
                        enforcement.--
                                    ``(I) In general.--Subject to 
                                subclause (II), on-site consultations 
                                and educational programming described 
                                in clause (i) shall be conducted 
                                independently of any enforcement 
                                activity.
                                    ``(II) Exception.--Subclause (I) 
                                shall not apply in the case where a 
                                triggering event at the nursing 
                                facility is observed in the course of 
                                providing on-site consultations and 
                                educational programming described in 
                                clause (i). In establishing such on-
                                site consultations and educational 
                                programming, the Secretary shall 
                                determine the triggering events for 
                                which the use of necessary enforcement 
                                actions is permitted notwithstanding 
                                the limitation under subclause (I). 
                                Such triggering events shall include 
                                events that are required to be reported 
                                under State and Federal law and a 
                                pattern of deficiencies or problems 
                                that the quality improvement 
                                organization or other organization has 
                                identified for correction but which are 
                                consistently not corrected.''.
    (c) Funding for the Special Focus Facility Program, Including 
Compliance Assistance Programs.--Section 1819(f)(8) of the Social 
Security Act (42 U.S.C. 1395i-3(f)(8)), as amended by subsections 
(a)(1) and (b)(1), is amended by adding at the end the following new 
subparagraph:
                    ``(E) For purposes of carrying out this paragraph 
                and section 1919(f)(10), there is appropriated to the 
                Secretary, out of any monies in the Treasury not 
                otherwise appropriated, $14,800,000 for fiscal year 
                2022 and each subsequent fiscal year, to remain 
                available until expended.''.

                    TITLE II--STAFFING IMPROVEMENTS

SEC. 201. NURSE STAFFING REQUIREMENTS.

    (a) In General.--Title XI of the Social Security Act (42 U.S.C. 
1301 et seq.) is amended by inserting after section 1128K the following 
new section:

``SEC. 1128L. NURSE STAFFING REQUIREMENTS FOR FACILITIES.

    ``(a) Study.--Not later than 3 years after the date of the 
enactment of this section, and not less frequently than once every 5 
years thereafter, the Secretary shall conduct a study and submit to 
Congress a report on the appropriateness of establishing minimum staff 
to resident ratios for nursing staff for skilled nursing facilities (as 
defined in section 1819(a)) and nursing facilities (as defined in 
section 1919(a)). Each such report shall include--
            ``(1) with respect to the first such report, 
        recommendations regarding appropriate minimum ratios of 
        registered nurses (and, if practicable, licensed practical 
        nurses (or licensed vocational nurses) and certified nursing 
        assistants) to residents at such skilled nursing facilities and 
        such nursing facilities; and
            ``(2) with respect to each subsequent such report, 
        recommendations regarding appropriate minimum ratios of 
        registered nurses, licensed practical nurses (or licensed 
        vocational nurses), and certified nursing assistants to 
        residents at such skilled nursing facilities and such nursing 
        facilities.
    ``(b) Promulgation of Regulations.--
            ``(1) In general.--Not later than 2 years after the 
        Secretary first submits a report under subsection (a), the 
        Secretary shall--
                    ``(A) specify through regulations, consistent with 
                such report, appropriate minimum ratios (if any) of 
                registered nurses (and, if practicable, licensed 
                practical nurses (or licensed vocational nurses) and 
                certified nursing assistants) to residents at skilled 
                nursing facilities and nursing facilities; and
                    ``(B) subject to any waiver in effect under section 
                1819(b)(9)(B) or 1919(b)(9)(B), require such skilled 
                nursing facilities and such nursing facilities to 
                comply with such ratios.
            ``(2) Update.--Not later than 2 years after the submission 
        of each subsequent report under subsection (a), the Secretary 
        shall, consistent with such report, update the regulations 
        described in paragraph (1)(A) to reflect appropriate minimum 
        ratios (if any) of registered nurses, licensed practical nurses 
        (or licensed vocational nurses), and certified nursing 
        assistants to residents at skilled nursing facilities and 
        nursing facilities.
    ``(c) Funding.--The Secretary shall provide for the transfer, from 
the Federal Hospital Insurance Trust Fund under section 1817 to the 
Centers for Medicare & Medicaid Services Program Management Account, of 
$50,000,000 for fiscal year 2022 for purposes of carrying out this 
section. Amounts transferred pursuant to the previous sentence shall 
remain available until expended.''.
    (b) Imposition of Requirements.--
            (1) Medicare.--Section 1819(b) of the Social Security Act 
        (42 U.S.C. 1395i-3(b)) is amended by adding at the end the 
        following new paragraph:
            ``(9) Nurse staffing requirement.--
                    ``(A) In general.--Subject to subparagraph (B), a 
                skilled nursing facility shall comply with any minimum 
                staffing ratios for registered nurses, licensed 
                practical nurses (or licensed vocational nurses), or 
                certified nurse assistants specified by the Secretary 
                for such a facility in regulations promulgated under 
                section 1128L(b) or, if greater, as specified by the 
                State involved for such a facility.
                    ``(B) Waiver.--
                            ``(i) In general.--The Secretary may waive 
                        the application of subparagraph (A) with 
                        respect to a skilled nursing facility if the 
                        Secretary finds that--
                                    ``(I) the facility is located in a 
                                rural area and the supply of skilled 
                                nursing facility services in such area 
                                is not sufficient to meet the needs of 
                                individuals residing therein;
                                    ``(II) the Secretary provides 
                                notice of the waiver to the State long-
                                term care ombudsman (established under 
                                section 307(a)(12) of the Older 
                                Americans Act of 1965) and the 
                                protection and advocacy system in the 
                                State for the mentally ill and the 
                                mentally retarded; and
                                    ``(III) the facility that is 
                                granted such a waiver notifies 
                                residents of the facility (or, where 
                                appropriate, the guardians or legal 
                                representatives of such residents) and 
                                members of their immediate families of 
                                the waiver.
                            ``(ii) Renewal.--Any waiver in effect under 
                        this subparagraph shall be subject to annual 
                        renewal.''.
            (2) Medicaid.--Section 1919(b) of the Social Security Act 
        (42 U.S.C. 1396r(b)) is amended by adding at the end the 
        following new paragraph:
            ``(9) Nurse staffing requirement.--
                    ``(A) In general.--Subject to subparagraph (B), a 
                nursing facility shall comply with any minimum staffing 
                ratios for registered nurses, licensed practical nurses 
                (or licensed vocational nurses), or certified nurse 
                assistants specified by the Secretary for such a 
                facility in regulations promulgated under section 
                1128L(b) or, if greater, as specified by the State 
                involved for such a facility.
                    ``(B) Waiver.--
                            ``(i) In general.--The Secretary may waive 
                        the application of subparagraph (A) with 
                        respect to a nursing facility if the Secretary 
                        finds that--
                                    ``(I) the facility is located in a 
                                rural area and the supply of nursing 
                                facility services in such area is not 
                                sufficient to meet the needs of 
                                individuals residing therein;
                                    ``(II) the Secretary provides 
                                notice of the waiver to the State long-
                                term care ombudsman (established under 
                                section 307(a)(12) of the Older 
                                Americans Act of 1965) and the 
                                protection and advocacy system in the 
                                State for the mentally ill and the 
                                mentally retarded; and
                                    ``(III) the facility that is 
                                granted such a waiver notifies 
                                residents of the facility (or, where 
                                appropriate, the guardians or legal 
                                representatives of such residents) and 
                                members of their immediate families of 
                                the waiver.
                            ``(ii) Renewal.--Any waiver in effect under 
                        this subparagraph shall be subject to annual 
                        renewal.''.

SEC. 202. IMPROVING NURSING HOME COMPARE STAFFING DATA.

    (a) Medicare.--Section 1819(i)(1)(A)(i) of the Social Security Act 
(42 U.S.C. 1395i-3(i)(1)(A)(i)) is amended by inserting ``(excluding, 
with respect to such data provided on or after October 1, 2022, any 
hours spent on administrative duties by licensed nurse staff) and, 
beginning October 1, 2022, data on the hours of care provided per 
resident per weekend day'' after ``per resident per day''.
    (b) Medicaid.--Section 1919(i)(1)(A)(i) of the Social Security Act 
(42 U.S.C. 1396r(i)(1)(A)(i)) is amended by inserting ``(excluding, 
with respect to such data provided on or after October 1, 2022, any 
hours spent on administrative duties by licensed nurse staff) and, 
beginning October 1, 2022, data on the hours of care provided per 
resident per weekend day'' after ``per resident per day''.

SEC. 203. ENSURING THE SUBMISSION OF ACCURATE STAFFING DATA.

    Section 1128I(g) of the Social Security Act (42 U.S.C. 1320a-7j(g)) 
is amended--
            (1) by redesignating paragraphs (1) through (4) as 
        subparagraphs (A) through (D), respectively, and adjusting the 
        margins accordingly;
            (2) in subparagraph (D), as so redesignated, by striking 
        ``paragraph (1)'' and inserting ``subparagraph (A)'';
            (3) by moving the flush matter following subparagraph (D), 
        as so redesignated, 2 ems to the right;
            (4) by striking ``Beginning not later than'' and inserting 
        the following:
            ``(1) In general.--Beginning not later than''; and
            (5) by adding at the end the following new paragraph:
            ``(2) Penalty for submission of inaccurate information.--
        Any facility that submits inaccurate information to the 
        Secretary under paragraph (1) may be subject to a civil 
        monetary penalty not to exceed $10,000 for each such 
        submission. The provisions of section 1128A (other than 
        subsections (a) and (b) of such section) shall apply to a civil 
        money penalty under the preceding sentence in the same manner 
        as such provisions apply to a penalty or proceeding under 
        section 1128A(a).''.

SEC. 204. REQUIRING 24-HOUR USE OF REGISTERED PROFESSIONAL NURSES.

    (a) Medicare.--Section 1819(b)(4)(C)(i) of the Social Security Act 
(42 U.S.C. 1395i-3(b)(4)(C)(i)) is amended by striking ``registered 
professional nurse'' and all that follows through the period at the end 
and inserting the following: ``registered professional nurse, with 
respect to such services furnished--
                                    ``(I) before October 1, 2023, at 
                                least 8 consecutive hours a day, 7 days 
                                a week; and
                                    ``(II) on or after such date, 24 
                                hours a day, 7 days a week.''.
    (b) Medicaid.--Section 1919(b)(4)(C)(i)(II) of the Social Security 
Act (42 U.S.C. 1396r(b)(4)(C)(i)(II)) is amended by striking 
``registered professional nurse'' and all that follows through the 
period at the end and inserting the following: ``registered 
professional nurse, with respect to such services furnished--
                                            ``(aa) before October 1, 
                                        2023, at least 8 consecutive 
                                        hours a day, 7 days a week; and
                                            ``(bb) on or after such 
                                        date, 24 hours a day, 7 days a 
                                        week.''.

SEC. 205. PROVISION OF INFECTION CONTROL SERVICES.

    (a) Medicare.--Section 1819(d)(3) of the Social Security Act (42 
U.S.C. 1395i-3(d)(3)) is amended--
            (1) by redesignating subparagraphs (A) and (B) as clauses 
        (i) and (ii) respectively, and moving such clauses 2 ems to the 
        right;
            (2) by striking ``environment.--A skilled'' and inserting 
        ``environment.--
                    ``(A) In general.--A skilled'';
            (3) in subparagraph (A), as amended by paragraphs (1) and 
        (2)--
                    (A) in clause (i), by striking ``, and'' at the end 
                and inserting a semicolon;
                    (B) in clause (ii), by striking the period at the 
                end and inserting ``; and''; and
                    (C) by adding at the end the following new clause:
                            ``(iii) provide, directly or under 
                        arrangements with others, for infection control 
                        services overseen by an infection preventionist 
                        for a minimum number of hours per week as 
                        determined appropriate by the Secretary (but, 
                        subject to subparagraph (B), not less than 40 
                        hours per week).''; and
            (4) by adding at the end the following new subparagraph:
                    ``(B) Reduction in required number of hours for 
                infection control services overseen by an infection 
                preventionist.--
                            ``(i) In general.--The Secretary may grant 
                        a waiver to a skilled nursing facility under 
                        which the number of hours per week that 
                        infection control services overseen by an 
                        infection preventionist at the facility are 
                        required under subparagraph (A)(iii) are 
                        reduced if the Secretary finds that--
                                    ``(I) the facility--
                                            ``(aa) is located in a 
                                        rural area and the supply of 
                                        skilled nursing facility 
                                        services in such area is not 
                                        sufficient to meet the needs of 
                                        individuals residing therein; 
                                        or
                                            ``(bb) is of a size that 
                                        necessitates a lower 
                                        requirement;
                                    ``(II) the Secretary provides 
                                notice of the waiver to the State Long-
                                Term Care Ombudsman (supported under 
                                title III or chapter 2 of subtitle A of 
                                title VII of the Older Americans Act of 
                                1965) and the protection and advocacy 
                                system (as defined in section 102 of 
                                the Developmental Disabilities 
                                Assistance and Bill of Rights Act of 
                                2000) in the State; and
                                    ``(III) the facility that is 
                                granted the waiver notifies residents 
                                of the facility (or, where appropriate, 
                                the guardians or legal representatives 
                                of such residents) and members of their 
                                immediate families of the waiver.
                            ``(ii) Annual review.--A waiver under this 
                        subparagraph shall be subject to annual review 
                        by the Secretary.''.
    (b) Medicaid.--Section 1919(d)(3) of the Social Security Act (42 
U.S.C. 1396r(d)(3)) is amended--
            (1) by redesignating subparagraphs (A) and (B) as clauses 
        (i) and (ii) respectively, and moving such clauses 2 ems to the 
        right;
            (2) by striking ``environment.--A nursing facility'' and 
        inserting ``environment.--
                    ``(A) In general.--A nursing facility'';
            (3) in subparagraph (A), as amended by paragraphs (1) and 
        (2)--
                    (A) in clause (i), by striking ``, and'' at the end 
                and inserting a semicolon;
                    (B) in clause (ii), by striking the period at the 
                end and inserting ``; and''; and
                    (C) by adding at the end the following new clause:
                            ``(iii) provide, directly or under 
                        arrangements with others, for infection control 
                        services overseen by an infection preventionist 
                        for a minimum number of hours per week as 
                        determined appropriate by the Secretary (but, 
                        subject to subparagraph (B), not less than 40 
                        hours per week).''; and
            (4) by adding at the end the following new subparagraph:
                    ``(B) Reduction in required number of hours for 
                infection control services overseen by an infection 
                preventionist.--
                            ``(i) In general.--A State may grant a 
                        waiver to a nursing facility under which the 
                        number of hours per week that infection control 
                        services overseen by an infection preventionist 
                        at the facility are required under subparagraph 
                        (A)(iii) are reduced if--
                                    ``(I) the facility demonstrates to 
                                the satisfaction of the State that the 
                                facility has been unable, despite 
                                diligent efforts (including offering 
                                wages at the community prevailing rate 
                                for nursing facilities), to recruit 
                                appropriate personnel;
                                    ``(II) the State determines that 
                                the waiver will not endanger the health 
                                or safety of individuals staying in the 
                                facility;
                                    ``(III) the State agency granting 
                                the waiver provides notice of the 
                                waiver to the State Long-Term Care 
                                Ombudsman (supported under title III or 
                                chapter 2 of subtitle A of title VII of 
                                the Older Americans Act of 1965) and 
                                the protection and advocacy system (as 
                                defined in section 102 of the 
                                Developmental Disabilities Assistance 
                                and Bill of Rights Act of 2000); and
                                    ``(IV) the nursing facility that is 
                                granted the waiver by a State notifies 
                                residents of the facility (or, where 
                                appropriate, the guardians or legal 
                                representatives of such residents) and 
                                members of their immediate families of 
                                the waiver.
                            ``(ii) Annual review.--A waiver under this 
                        subparagraph shall be subject to annual review 
                        by the State agency and to the review of the 
                        Secretary and subject to clause (iii) shall be 
                        accepted by the Secretary for purposes of this 
                        title to the same extent as is the State's 
                        certification of the facility. In granting or 
                        renewing a waiver, a State may require the 
                        facility to use other qualified, licensed 
                        personnel to meet the staffing requirements 
                        under subparagraph (A)(iii).
                            ``(iii) Assumption of waiver authority by 
                        secretary.--If the Secretary determines that a 
                        State has shown a clear pattern and practice of 
                        allowing waivers in the absence of diligent 
                        efforts by facilities to meet the staffing 
                        requirements under subparagraph (A)(iii), the 
                        Secretary shall assume and exercise the 
                        authority of the State to grant waivers.''.
    (c) Effective Date.--The amendments made by this section shall take 
effect on October 1, 2022.

SEC. 206. ENHANCED FUNDING TO SUPPORT STAFFING AND QUALITY CARE IN 
              NURSING FACILITIES.

    (a) FMAP Increase.--
            (1) In general.--Notwithstanding subsection (b) or (ff) of 
        section 1905 of the Social Security Act (42 U.S.C. 1396d), in 
        the case of a State that meets the requirements described in 
        subsection (c), the Federal medical assistance percentage 
        determined for the State under subsection (b) of section 1905 
        of such Act (or subsection (ff) of such section, if applicable) 
        and, if applicable, as increased under subsection (y), (z), 
        (aa), or (ii) of such section or section 6008 of the Families 
        First Coronavirus Response Act (Public Law 116-127), or any 
        other provision of law, shall be increased by the applicable 
        number of percentage points specified in paragraph (2) (but not 
        to exceed 95 percent) with respect to amounts expended by the 
        State Medicaid program for medical assistance for nursing 
        facility services provided for each calendar quarter that 
        occurs during the applicable period and for which the Secretary 
        determines that the State meets such requirements. Any payment 
        made to Puerto Rico, the Virgin Islands, Guam, the Northern 
        Mariana Islands, or American Samoa for expenditures on medical 
        assistance that are subject to the Federal medical assistance 
        percentage increase specified under the first sentence of this 
        paragraph shall not be taken into account for purposes of 
        applying payment limits under subsections (f) and (g) of 
        section 1108 of the Social Security Act (42 U.S.C. 1308).
            (2) Applicable number of percentage points.--For purposes 
        of paragraph (1), the applicable number of percentage points 
        specified in this paragraph is--
                    (A) in the case of a calendar quarter that occurs 
                within the 16-quarter period that begins on the 1st day 
                of the applicable period, 3 percentage points;
                    (B) in the case of a calendar quarter that occurs 
                within the 4-quarter period immediately succeeding such 
                16-quarter period, 2 percentage points; and
                    (C) in the case of a calendar quarter that occurs 
                within the 4-quarter period immediately succeeding the 
                4-quarter period described in subparagraph (B), 1 
                percentage point.
    (b) Definitions.--In this section:
            (1) Applicable period.--The term ``applicable period'' 
        means the period that--
                    (A) begins on the 1st day of the 1st calendar 
                quarter that begins on or after the date that is 1 year 
                after the date of enactment of this section; and
                    (B) ends on the last day of the succeeding 24th 
                calendar quarter.
            (2) Nursing facility staff.--The term ``nursing facility 
        staff'' includes a registered nurse, licensed practical nurse, 
        licensed nursing assistant, certified nursing assistant, 
        nursing assistant, and any other relevant staff, as determined 
        by the Secretary, who provide care to Medicaid beneficiaries 
        who are residents in a nursing facility.
            (3) Medicaid beneficiary.--The term ``Medicaid 
        beneficiary'' means an individual who is eligible for, and 
        enrolled in, a State Medicaid program.
            (4) Medicaid program.--The term ``Medicaid program'' means, 
        with respect to a State, the State program under title XIX of 
        the Social Security Act (42 U.S.C. 1396 et seq.) (including any 
        waiver or demonstration under such title or under section 1115 
        of such Act (42 U.S.C. 1315) relating to such title).
            (5) Nursing facility.--The term ``nursing facility''--
                    (A) has the meaning given such term in section 
                1919(a) of the Social Security Act (42 U.S.C. 1396r(a); 
                and
                    (B) includes a skilled nursing facility, as defined 
                in section 1819(a) of the Social Security Act (42 
                U.S.C. 1395i-3(a)), that is a participating provider in 
                the Medicaid program of the State in which the facility 
                is located or otherwise furnishes items or services for 
                which medical assistance is available under the 
                Medicaid program of the State in which the facility is 
                located.
            (6) Nursing facility services.--
                    (A) In general.--Subject to subparagraphs (B) and 
                (C), the term ``nursing facility services'' has the 
                meaning given such term under section 1905(f) of the 
                Social Security Act (42 U.S.C. 1396d(f)).
                    (B) State medicaid program.--With respect to a 
                State, such term includes those services (including any 
                limitations on the provision of, or payment for, such 
                services) that are specified as nursing facility 
                services for purposes of the Medicaid program of the 
                State in which the nursing facility furnishing such 
                services is located.
                    (C) Individual plan of care.--Notwithstanding 
                subparagraph (A) or (B), such term includes items or 
                services that are specified in the individual plan of 
                care for a resident of a nursing facility and are 
                furnished to the resident in accordance with the 
                requirements of such plan.
            (7) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.
            (8) State.--The term ``State'' has the meaning given such 
        term for purposes of title XIX of the Social Security Act (42 
        U.S.C. 1396 et seq.).
    (c) Requirements.--As a condition for receipt of the increase under 
subsection (a) to the Federal medical assistance percentage determined 
for a State under subsection (b) of section 1905 of the Social Security 
Act (42 U.S.C. 1396d) for a calendar quarter, the State shall 
demonstrate to the satisfaction of the Secretary the following:
            (1) Use of additional federal funds.--The State agrees to--
                    (A) use the Federal funds attributable to the 
                increase under subsection (a) only for the purposes 
                specified in subsection (d); and
                    (B) not use such Federal funds to satisfy any State 
                contribution required under the State Medicaid program.
            (2) Plan for staffing and service improvements and 
        reporting.--The State has a reasonable plan for achieving the 
        purposes specified in subsection (d), including with respect 
        to--
                    (A) carrying out the staffing and service 
                improvements specified in subsection (e) to strengthen 
                nursing facility staff workforce and improve the 
                quality and safety of care for Medicaid beneficiaries; 
                and
                    (B) collecting and reporting the information 
                required under subsection (f).
            (3) Supplement, not supplant.--The State agrees to use the 
        Federal funds attributable to the increase under subsection (a) 
        to supplement, and not supplant, the level of State funds 
        expended as of October 1, 2021, for nursing facility services, 
        including with respect to efforts to strengthen the nursing 
        facility staff workforce and improve the quality and safety of 
        care for Medicaid beneficiaries, under the State Medicaid 
        program.
            (4) Reporting and oversight.--The State agrees to--
                    (A) annually report the information specified in 
                subsection (f) to the Secretary in such form and manner 
                as the Secretary shall require; and
                    (B) provide such data and information as is 
                necessary for the evaluation required under subsection 
                (g).
    (d) Use of Funds.--A State may use the Federal funds attributable 
to the increase under subsection (a) only for expenditures eligible for 
payment under the State Medicaid program that are attributable to State 
efforts to achieve both of the following purposes:
            (1) To expand and improve nursing facility staffing, 
        including by increasing payments for nursing facility services 
        to improve staff wages and benefits, support retention and 
        recruitment, and reduce staff turnover, consistent with the 
        improvements specified in paragraphs (1) and (2) of subsection 
        (e).
            (2) To support and improve the quality and safety of care 
        provided to Medicaid beneficiaries in nursing facilities, 
        including through efforts to expand the use of person-centered 
        models of care, and incentives or payments related to the 
        provision of care for Medicaid beneficiaries in private rooms.
    (e) Staffing and Service Improvements.--The staffing and service 
improvements specified in this subsection are the following:
            (1) The State makes such changes to processes for 
        determining payment rates for nursing facility services as are 
        necessary to ensure that--
                    (A) such payment rates are reviewed and updated 
                every 2 years during the applicable period to support 
                the recruitment and retention of nursing facility 
                staff, and reduce turnover in such staff through a 
                transparent process that involves meaningful input from 
                stakeholders; and
                    (B) increases to such payment rates are, at a 
                minimum, used to proportionally increase wages and 
                benefits for nursing facility staff.
            (2) The State updates, develops, and adopts training 
        opportunities and resources for nursing facility staff, 
        including training for providing person-centered care.
            (3) The State improves and streamlines education and 
        options counseling services for Medicaid beneficiaries, 
        potential Medicaid beneficiaries, and family members of such 
        beneficiaries and potential beneficiaries, with respect to 
        eligibility and options for institutional and non-institutional 
        long term care.
    (f) Annually Reported Information.--The information required to be 
annually reported to the Secretary by a State with respect to such 
reporting periods as the Secretary shall specify is the following:
            (1) The number of Medicaid beneficiaries who received 
        during the reporting period or, as of the date of the report, 
        are receiving, nursing facility services in the State, 
        disaggregated by race, ethnicity, gender, geography, age, and 
        income.
            (2) A description of how the State spent the Federal funds 
        attributable to the increase under subsection (a) during the 
        reporting period.
            (3) Changes to payment rates for nursing facility services 
        under the State Medicaid program during the reporting period.
            (4) The staffing information and employee turnover and 
        tenure information in nursing facilities in the State during 
        the reporting period, based on submissions to the Payroll-Based 
        Journal system of the Centers for Medicare & Medicaid Services 
        under section 1128I(g) of the Social Security Act (42 U.S.C. 
        1320a-7j(g)).
            (5) The wages and benefits provided to nursing facility 
        staff in nursing facilities in the State during the reporting 
        period.
            (6) A description of the health status of, and quality of 
        care provided to, Medicaid beneficiaries who are residents of 
        nursing facilities in the State during the reporting period, in 
        the manner determined by the Secretary.
    (g) Evaluation.--The Secretary shall engage an external contractor 
to conduct an independent evaluation of the impact of this section on--
            (1) the quality and safety of care provided in nursing 
        facilities to Medicaid beneficiaries who are residents of 
        nursing facilities;
            (2) the capacity of the nursing facility staff workforce to 
        provide quality, safe care for Medicaid beneficiaries who are 
        residents of nursing facilities; and
            (3) the wages, benefits, and turnover of nursing facility 
        staff.
    (h) Interim and Final Reports to Congress.--
            (1) In general.--The Secretary shall submit an interim 
        report to Congress on the implementation of this section 4 
        years after the date of enactment of this section, and a final 
        report on the implementation of this section 8 years after such 
        date.
            (2) Required information.--
                    (A) Interim and final reports.--The interim and 
                final reports submitted under this subsection shall 
                include the following information:
                            (i) The number of States that received an 
                        increase to the Federal medical assistance 
                        percentage of the State under subsection (a) 
                        during the applicable period.
                            (ii) The State activities funded by the 
                        Federal funds attributable to the increase 
                        under subsection (a).
                    (B) Final report.--The final report submitted under 
                this section shall include, in addition to the 
                information required under subparagraph (A), the 
                results of the independent evaluation conducted 
                pursuant to subsection (g).

  TITLE III--BUILDING MODIFICATION AND STAFF INVESTMENT DEMONSTRATION 
                                PROGRAM

SEC. 301. ESTABLISHING A SKILLED NURSING FACILITY BUILDING MODIFICATION 
              AND STAFF INVESTMENT DEMONSTRATION PROGRAM.

    Part A of title XVIII of the Social Security Act (42 U.S.C. 1395c 
et seq.) is amended by inserting after section 1819 the following new 
section:

``SEC. 1819A. COMMUNITY-BASED LIVING MODIFICATIONS AND STAFF INVESTMENT 
              DEMONSTRATION PROGRAM.

    ``(a) Establishment.--Not later than January 1, 2023, the Secretary 
shall establish a demonstration program to test the impact of providing 
skilled nursing facilities (as defined in section 1819(a)) selected by 
the Secretary under subsection (b) funding to modify the built 
environments of such facilities (or portions of such facilities) and 
invest in individuals providing resident care in such facilities (or in 
portions of such facilities) in order to, with respect to residents of 
such facilities, improve health outcomes relative to residents of 
facilities not so selected.
    ``(b) Application and Selection of Facilities.--
            ``(1) Application.--
                    ``(A) In general.--A skilled nursing facility shall 
                only be eligible to receive funding under the 
                demonstration program established under subsection (a) 
                if such facility submits an application at such time 
                and in such manner as specified by the Secretary that 
                contains--
                            ``(i) a description of modifications and 
                        investments described in subsection (a) that 
                        will be made by the facility using such funds, 
                        including the estimated costs of such 
                        modifications and investments;
                            ``(ii) an agreement that such facility (or, 
                        in the case such modifications and investments 
                        are to be made only with respect to a portion 
                        of such facility, such portion of such 
                        facility)--
                                    ``(I) will meet the requirements 
                                described in subparagraph (B) not later 
                                than the date that is 2 years after 
                                such facility first receives funds for 
                                such modifications and investments 
                                under such program; and
                                    ``(II) will continue to meet such 
                                requirements for the 5-year period 
                                beginning on the date that is 2 years 
                                after such facilities first receives 
                                such funds;
                            ``(iii) an agreement that, in the case such 
                        facility (or such portion of such facility, as 
                        applicable) fails to meet such requirements in 
                        accordance with clause (ii), such facility 
                        will--
                                    ``(I) repay such funds to the 
                                Secretary in an amount determined 
                                appropriate by the Secretary under 
                                subsection (d); and
                                    ``(II) notify each resident of such 
                                facility (or each resident of such 
                                portion of such facility, as 
                                applicable) of the failure of such 
                                facility or such portion, as 
                                applicable, to meet such requirements;
                            ``(iv) an agreement that, if such facility 
                        is selected by the Secretary under paragraph 
                        (2), the facility will notify each resident of 
                        such facility (or each resident of such portion 
                        of such facility, as applicable), of such 
                        selection and include in such notification a 
                        description of the program established under 
                        subsection (a), including any modifications and 
                        investments to be made with respect to such 
                        facility (or with respect to such portion of 
                        such facility, as applicable); and
                            ``(v) in the case such modifications and 
                        investments are to be made only with respect to 
                        a portion of such facility, an agreement that 
                        such facility will not discriminate in the 
                        selection of residents who may reside in such 
                        portion based on whether payment is being made 
                        to such facility with respect to such resident 
                        under this title, a State plan (or waiver of 
                        such plan) under title XIX, or otherwise.
                    ``(B) Requirements.--For purposes of subparagraph 
                (A), the requirements described in this subparagraph 
                with respect to a skilled nursing facility (or a 
                portion of such facility) are the following:
                            ``(i) The facility (or portion) maintains 
                        beds for no less than 5 and no more than 14 
                        residents.
                            ``(ii) The facility (or portion) 
                        incorporates universal design (defined in 
                        section 3(19) of the Assistive Technology Act 
                        of 1998)) to ensure such facility (or portion) 
                        is accessible to all residents, regardless of 
                        age or disability, including by providing for 
                        the following:
                                    ``(I) Private rooms and bathrooms 
                                (unless such facility determines that 
                                the provision of private rooms and 
                                bathrooms at such facility would 
                                adversely affect the availability of 
                                skilled nursing facility services in 
                                the area in which such facility is 
                                located and the Secretary concurs with 
                                such determination).
                                    ``(II) Shared space, including a 
                                central living area, as defined by the 
                                Secretary, with a communal dining table 
                                and accessible kitchen.
                                    ``(III) Accessible outdoor space, 
                                including a protected garden space for 
                                use by residents and their visitors.
                            ``(iii) The facility (or portion) provides 
                        a clinical team that consists of a full-time 
                        registered professional nurse or licensed 
                        practical nurse (or licensed vocational nurse) 
                        who works in partnership with certified nursing 
                        assistants in a team-based, collaborative 
                        model.
                            ``(iv) The facility (or portion) has a 
                        licensed practical nurse (or licensed 
                        vocational nurse) on site at all times.
                            ``(v) The facility (or portion) facilitates 
                        a standing resident council run by residents, 
                        and a standing family council run by family 
                        members of residents, that meets such 
                        requirements as may be specified by the 
                        Secretary.
                            ``(vi) The facility (or portion) solicits 
                        resident input on facility policies (or 
                        policies relating to such portion of such 
                        facility), including with respect to programs 
                        and scheduling, and, in the case of an 
                        incapacitated resident, solicits such input 
                        from an individual recognized by State law to 
                        act on behalf of such resident.
                            ``(vii) In addition to the resident 
                        assessment under section 1819(b)(3), the 
                        facility (or portion) conducts an assessment of 
                        residents' care preferences (or, in the case of 
                        an incapacitated resident, such preferences as 
                        expressed by an individual recognized by State 
                        law to act on behalf of such resident) not 
                        later than 14 days after the resident is 
                        admitted to such facility or portion of such 
                        facility (or, in the case of a resident 
                        residing at such facility at the time such 
                        facility receives funding under the program 
                        established under paragraph (1), not later than 
                        14 days after the date of such receipt) to 
                        ensure care is person-directed.
                            ``(viii) The facility (or portion) offers 
                        daily activities, such as art, music, 
                        educational activities, or other activities 
                        based on resident preferences.
                    ``(C) Timeframe.--The Secretary shall develop the 
                application described in subparagraph (A) and begin 
                accepting such applications not later than July 1, 
                2023. The Secretary shall accept such applications 
                during the 2-year period beginning on the date such 
                applications are first accepted.
            ``(2) Selection.--
                    ``(A) In general.--Not later than 2 years after the 
                date the Secretary first accepts applications under 
                paragraph (1), the Secretary shall select a number of 
                skilled nursing facilities determined appropriate by 
                the Secretary to receive funding under the program 
                established under subsection (a).
                    ``(B) Preference.--In selecting skilled nursing 
                facilities under this paragraph, the Secretary shall--
                            ``(i) give preference to facilities that--
                                    ``(I) are located in medically 
                                underserved areas (as defined in 
                                section 330(b)(3)(A) of the Public 
                                Health Service Act); and
                                    ``(II) house a majority of 
                                residents who are receiving medical 
                                assistance consisting of nursing 
                                facility services under a State plan 
                                (or waiver of such plan) under title 
                                XIX;
                            ``(ii) give preference to facilities that 
                        demonstrate the greatest likelihood of meeting 
                        the requirements described in paragraph (1)(B) 
                        within 2 years of receiving funding under the 
                        program established under subsection (a);
                            ``(iii) give preference to facilities that 
                        offer staff training beyond such training 
                        required under section 1819 (as determined 
                        through payroll based journal data); and
                            ``(iv) so select such facilities in a 
                        manner that ensures geographic diversity, to 
                        the extent practicable.
    ``(c) Funds.--
            ``(1) In general.--Subject to paragraph (3) and subsection 
        (h), the Secretary shall provide funds to each skilled nursing 
        facility selected under subsection (b)(2) in an amount equal to 
        not more than the costs specified by such facility pursuant to 
        subsection (b)(1)(A)(i).
            ``(2) Use of funds.--
                    ``(A) In general.--Subject to subparagraph (B), 
                funds provided under paragraph (1) may only be used by 
                a skilled nursing facility for modifications and 
                investments specified by such facility pursuant to 
                subsection (b)(1)(A)(i).
                    ``(B) Exception.--A skilled nursing facility may 
                use funds provided under paragraph (1) for 
                modifications and investments described in subsection 
                (a) but not specified by such facility pursuant to 
                subsection (b)(1)(A)(i) if--
                            ``(i) such facility submits a request to 
                        the Secretary containing a description of such 
                        modifications and investments; and
                            ``(ii) the Secretary determines that such 
                        modifications and investments will assist such 
                        facility (or a portion of such facility, as 
                        applicable) in complying with the requirements 
                        specified in subsection (b)(1)(B).
            ``(3) Form of provision of funds.--The Secretary may 
        provide funding under paragraph (1) in the form of a single 
        upfront payment or in up to 3 installment payments, spaced out 
        across the first 3 fiscal years beginning with the fiscal year 
        in which the first such payment is made.
            ``(4) Limitation of provision of funding.--No skilled 
        nursing facility may receive more than 3 percent of the total 
        monies appropriated under paragraph (5).
            ``(5) Appropriation.--In addition to any amounts otherwise 
        available, there is appropriated to the Secretary, out of any 
        monies in the Treasury not otherwise appropriated, 
        $1,300,000,000, to remain available until expended, for 
        purposes of providing funds to skilled nursing facilities under 
        paragraph (1).
    ``(d) Failure To Meet Requirements.--
            ``(1) In general.--Subject to paragraph (2), in the case of 
        a facility (or a portion of such facility, as applicable) that 
        fails to meet the requirements described in subsection 
        (b)(1)(B) in accordance with the agreement described in 
        subsection (b)(1)(A)(ii), the Secretary may recoup any funds 
        provided to such facility under subsection (c)(1) in an amount 
        determined appropriate by the Secretary. In determining such 
        amount, the Secretary shall take into account the extent of the 
        compliance of such facility (or portion of such facility, as 
        applicable) with such requirements.
            ``(2) Exception.--The Secretary may suspend any recoupment 
        described in paragraph (1) with respect to a facility (or a 
        portion of such facility, as applicable) described in such 
        paragraph for a period of time determined appropriate by the 
        Secretary if the Secretary finds that such facility (or such 
        portion) will likely be in compliance with the requirements 
        described in such paragraph within a reasonable time specified 
        by the Secretary.
    ``(e) Evaluation of Program.--
            ``(1) In general.--The Secretary shall evaluate each 
        skilled nursing facility receiving funds under the program 
        established under subsection (a) to assess whether, relative to 
        similarly situated skilled nursing facilities not receiving 
        funds under such program and residents of such facilities, 
        modifications and investments described in subsection (a) made 
        at skilled nursing facilities using such funds resulted in, 
        with respect to residents of such facilities (or, in the case 
        such modifications and investments are made only with respect 
        to a portion of such facility, residents of such portion of 
        such facility)--
                    ``(A) a reduction in preventable hospitalizations;
                    ``(B) a reduction in hospital readmissions;
                    ``(C) a reduction in emergency room visits;
                    ``(D) greater improvement in functional status;
                    ``(E) an improvement in infection control;
                    ``(F) a reduction in nursing staff turnover rates;
                    ``(G) an increase in resident and family caregiver 
                satisfaction;
                    ``(H) other improvements in resident quality of 
                life as may be specified by the Secretary;
                    ``(I) a reduction in expenditures under this part 
                (excluding funds provided under subsection (c)(1)); or
                    ``(J) any other outcomes specified by the 
                Secretary.
            ``(2) Reports to congress.--Based on evaluations described 
        in paragraph (1), the Secretary shall, not later than July 1, 
        2031, and again not later than July 1, 2035, submit to Congress 
        a report on such program. Each such report shall include an 
        analysis of the demonstration program's effect on the outcomes 
        described in paragraph (1).
    ``(f) Implementation.--Chapter 35 of title 44, United States Code, 
shall not apply to this section.
    ``(g) Authority To Expand to Certain Nursing Facilities.--The 
Secretary may, subject to subsection (h), enter into agreements with 
States to include nursing facilities (as defined in section 1919(a)) 
that are not skilled nursing facilities (as defined in section 1819(a)) 
in the demonstration program established under subsection (a) and may 
modify the requirements of the previous provisions of this section as 
appropriate to be applicable to such facilities.
    ``(h) Funding.--The Secretary shall provide for the transfer, from 
the Federal Hospital Insurance Trust Fund under 1817 to the Centers for 
Medicare & Medicaid Services Program Management Account, of $30,000,000 
for fiscal year 2023 for purposes of carrying out this section (other 
than for purposes of making payments under subsection (c)(1)). Amounts 
transferred pursuant to the previous sentence shall remain available 
until expended.''.
                                 <all>
Nursing Home Improvement and Accountability Act of 2021
To improve care furnished and to support the workforce in skilled nursing facilities under the Medicare program and in nursing facilities under the Medicaid program, and for other purposes.
Nursing Home Improvement and Accountability Act of 2021
Rep. Neal, Richard E.