======= art.010/6/010/5/010/4/010/3/010/2/010/1 ======= ARTICLE 10 RELATING TO HEALTH AND HUMAN SERVICES SECTION 1. Sections 23-14.1-2, 23-14.1-3, 23-14.1-4, 23-14.1-5, 23-14.1-6, 23-14.1-8 and 23-14.1-9 of the General Laws in Chapter 23-14.1 entitled "Health Professional Loan Repayment Program" are hereby amended to read as follows: 23-14.1-2. Definitions. For the purpose of this chapter, the following words and terms have the following meanings unless the context clearly requires otherwise: (1) “Board” means the health professional loan repayment board. (2) “Commissioner” means the commissioner of postsecondary education. (3) (2) “Community health center” means a healthcare facility as defined and licensed under chapter 17 of this title. (4) (3) “Division” "Department" means the Rhode Island division of higher education assistance department of health . (5) (4) "Director" means the director of the Rhode Island department of health. (5) “Eligible health professional” means a physician, dentist, dental hygienist, nurse practitioner, certified nurse midwife, physician assistant, or any other eligible healthcare professional under § 338A of the Public Health Service Act, 42 U.S.C. § 254l, licensed in the state who has entered into a contract with the board to serve medically underserved populations. (6) “Loan repayment” means an amount of money to be repaid to satisfy loan obligations incurred to obtain a degree or certification in an eligible health profession as defined in subdivision (5). 23-14.1-3. Health professional loan repayment program established. There is established within the division department , to be administered by the commissioner director , the health professional loan repayment program whose purpose shall be to provide support the recruitment and retention of high-quality health professionals working with underserved populations in identified health professional shortage areas (HPSAs) by providing loan repayment to eligible health professionals to defray the cost of their professional education. 23-14.1-4. Health professional loan repayment board. (a) There is created the health professional loan repayment board, which shall consist of the director of the department of health and eight (8) nine (9) members appointed by the governor with the advice and consent of the senate. The governor shall give due consideration to any recommendations for nominations submitted to him or her the governor by the department, the Rhode Island Medical Society; the Rhode Island Dental Association; the Rhode Island Health Center Association; the dean of the Brown University Medical School; the dean of the College of Nursing at the University of Rhode Island; the Rhode Island State Nurses’ Association; the Hospital Association of Rhode Island; and the Rhode Island division of higher education assistance office of the postsecondary commissioner . All appointed members shall serve for terms of three (3) years and shall receive no compensation for their services. Board members shall be eligible to succeed themselves. (b) The director of the department of health shall serve as chairperson. The board shall elect such other officers as it deems necessary from among its members. All meetings shall be called by the chairperson. (c) Members of the board shall be removable by the governor pursuant to the provisions of § 36-1-7 and for cause only, and removal solely for partisan or personal reasons unrelated to capacity or fitness for the office shall be unlawful. 23-14.1-5. Duties of the board. The board shall: (1) Determine which areas of the state shall be eligible to participate in the loan repayment program each year, based on health professional shortage area designations . ; (2) Receive and consider all applications for loan repayment made by eligible health professionals . ; (3) Conduct a careful and full investigation of the ability, character, financial needs, and qualifications of each applicant . ; (4) Consider the intent of the applicant to practice in a health professional shortage area and to adhere to all the requirements for participation in the loan repayment program . ; (5) Submit to the commissioner director a list of those individuals eligible for loan repayment and amount of loan repayment to be granted . ; (6) Promulgate rules and regulations to ensure an effective implementation and administration of the program . ; (7) Within ninety (90) days after the end of each fiscal year, the board shall approve and submit an annual report to the governor, the speaker of the house of representatives, the president of the senate, and the secretary of state, of its activities during that fiscal year. The report shall provide: an operating statement summarizing meetings or hearings held, including meeting minutes, subjects addressed, decisions rendered, applications considered and their disposition, rules or regulations promulgated, studies conducted, polices and plans developed, approved, or modified, and programs administered or initiated; a consolidated financial statement of all funds received and expended including the source of the funds, a listing of any staff supported by these funds, and a summary of any clerical, administrative , or technical support received; a summary of performance during the previous fiscal year including accomplishments, shortcomings , and remedies; a synopsis of hearings, complaints, suspensions, or other legal matters related to the committee; a summary of any training courses held pursuant to this chapter; a briefing on anticipated activities in the upcoming fiscal year, and findings and recommendations for improvements. The report shall be posted electronically on the websites of the general assembly and the secretary of state pursuant to the provisions of § 42-20-8.2. The director of the department of administration shall be responsible for the enforcement of the provisions of this subsection . ; and (8) Conduct a training course for newly appointed and qualified members within six (6) months of their qualification or designation. The course shall be developed by the chair of the board, be approved by the board, and be conducted by the chair of the board. The board may approve the use of any board and/or staff members and/or individuals to assist with training. The training course shall include instruction in the following areas: the provisions of chapter 46 of title 42, chapter 14 of title 36, chapter 2 of title 38; and the board’s rules and regulations. The director of the department of administration shall, within ninety (90) days of June 16, 2006, prepare and disseminate training materials relating to the provisions of chapter 46 of title 42, chapter 14 of title 36, and chapter 2 of title 38. 23-14.1-6. Duties of the commissioner Duties of the director. The commissioner director shall: (1) Grant loan repayments to successful applicants as determined by the board. (2) Enter into contracts, on behalf of the division department with each successful applicant, reflecting the purpose and intent of this chapter. (3) Be authorized to implement legal proceedings against eligible health professionals participating in the Rhode Island health professional loan repayment program determined by the director to be in default or breach of contract. 23-14.1-8. Contracts required. Prior to being granted loan repayment, each eligible health professional shall enter into a contract with the division department agreeing to the terms and conditions upon which the loan repayment is granted. The contract shall include any provisions that are required to fulfill the purposes of this chapter and those deemed advisable by the commissioner director . 23-14.1-9. Penalty for failure to complete contract. (a) If the recipient of a loan repayment fails, without justifiable cause, to practice pursuant to the terms and conditions of his or her contract with the division, a penalty for the failure to complete the contract will be imposed. If the recipient fails to complete the period of obligated service, he or she shall be liable to the state of Rhode Island for If the eligible health professional fails to begin or fails to complete service, they will incur a debt to the State state in an amount not less than the damages that would be owed under the National Health Service Corps Loan Repayment Program default provisions pursuant to 42 U.S.C. 6(A), Subchapter II, Part D, Subpart iii, § 254o. Upon determination by the director, if that the eligible health professional has failed to fulfill the terms and conditions of the contract, and no exception has been determined under subsection (c) , the eligible health professional shall pay an amount equal to the sum of the following : (1) An amount equal to the total paid on behalf of the recipient The total of the amounts paid by the director on behalf of the eligible health professional for any period of obligated service not served ; and (2) An unserved obligation penalty equal to the number of months of obligated service not completed by the recipient multiplied by one thousand dollars ($1,000) An amount equal to the number of months of obligated service not served, multiplied by seven thousand five hundred dollars ($7,500); and (3) Interest on the above amounts at the maximum legal prevailing rate, as determined by the Treasurer of the United States, from the date of breach; except that the amount to recover will not be less than thirty one thousand dollars ($31,000) . (b) If the recipient fails to complete one year of service, he or she shall be liable to the state of Rhode Island for: (1) An amount equal to the total paid on behalf of the recipient; and (2) An unserved obligation penalty equal to the number of months in the full period multiplied by one thousand dollars ($1,000). All payments pursuant to § 23-14.1-9 (a)(1), (a)(2), and (a)(3) of this section hereof shall be made to the State state of Rhode Island, for the benefit of the Rhode Island health professional loan repayment program, within one year after being notified by the director in writing that the eligible health professional has failed to abide by the terms and conditions of their contract. The director is authorized to recover payments and/or penalties and return the funds to the Rhode Island health professional loan repayment program to avoid having the amounts deducted from the department’s federal grant by the federal grant funding authority. Eligible health professionals are considered to be in default or breach if they do not complete the period of obligated service at an eligible site in accordance with their contract, or otherwise fail to comply with the terms of their contract, even if no monies have yet been disbursed to or on behalf of the participant. (c) Any amount owed shall be paid to the state of Rhode Island within one year of the date that the recipient is in breach of contract. (d) (c) Where the commissioner director , subject to the approval of the board and/or as defined in regulation , determines that there exists justifiable cause for the failure of a recipient to practice pursuant to the terms and conditions of the contract, he or she the director may relieve the recipient of the obligation to fulfill any or all of the terms of the contract. SECTION 2. Sections 23-17.5-32, 23-17.5-33 and 23-17.5-34 of the General Laws in Chapter 23-17.5 entitled "Rights of Nursing Home Patients" are hereby amended to read as follows: 23-17.5-32. Minimum staffing levels. (a) Each facility shall have the necessary nursing service personnel (licensed and non- licensed) in sufficient numbers on a twenty-four (24) hour basis, to assess the needs of residents, to develop and implement resident care plans, to provide direct resident care services, and to perform other related activities to maintain the health, safety, and welfare of residents. The facility shall have a registered nurse on the premises twenty-four (24) hours a day. (b) For purposes of this section, the following definitions shall apply: (1) “Direct caregiver” means a person who receives monetary compensation as an employee of the nursing facility or a subcontractor as a registered nurse, a licensed practical nurse, a medication technician, a certified nurse assistant, a licensed physical therapist, a licensed occupational therapist, a licensed speech-language pathologist, a mental health worker who is also a certified nurse assistant, or a physical therapist assistant , social worker, or any nurse aide with a valid license, even if it is probationary . (2) “Hours of direct nursing care” means the actual hours of work performed per patient day by a direct caregiver. (c) (i) Commencing on January 1, 2022 2026 , nursing facilities shall provide a quarterly minimum average of three and fifty-eight hundredths (3.58) hours of direct nursing care per resident, per day , of which at least two and forty-four hundredths (2.44) hours shall be provided by certified nurse assistants . (ii) Commencing on January 1, 2023, nursing facilities shall provide a quarterly minimum of three and eighty-one hundredths (3.81) hours of direct nursing care per resident, per day, of which at least two and six-tenths (2.6) hours shall be provided by certified nurse assistants. (d) Director of nursing hours and nursing staff hours spent on administrative duties or non- direct caregiving tasks are excluded and may not be counted toward compliance with the minimum staffing hours requirement in this section. (e) The minimum hours of direct nursing care requirements shall be minimum standards only. Nursing facilities shall employ and schedule additional staff as needed to ensure quality resident care based on the needs of individual residents and to ensure compliance with all relevant state and federal staffing requirements. (f) The department shall promulgate rules and regulations to amend the Rhode Island code of regulations in consultation with stakeholders to implement these minimum staffing requirements on or before October 15, 2021. (g) On or before January 1, 2024, and every five (5) years thereafter, the department shall consult with consumers, consumer advocates, recognized collective bargaining agents, and providers to determine the sufficiency of the staffing standards provided in this section and may promulgate rules and regulations to increase the minimum staffing ratios to adequate levels. 23-17.5-33. Minimum staffing level compliance and enforcement program. (a) Compliance determination. (1) The department shall submit proposed rules and regulations for adoption by October 15, 2021, establishing a system for determining compliance with minimum staffing requirements set forth in § 23-17.5-32. (2) Compliance shall be determined quarterly by comparing the number of hours provided per resident, per day using the Centers for Medicare and Medicaid Services’ payroll-based journal and the facility’s daily census, as self-reported by the facility to the department on a quarterly basis. (3) The department shall use the quarterly payroll-based journal and the self-reported census to calculate the number of hours provided per resident, per day and compare this ratio to the minimum staffing standards required under § 23-17.5-32. Discrepancies between job titles contained in § 23-17.5-32 and the payroll-based journal shall be addressed by rules and regulations. (b) Monetary penalties. (1) The department shall submit proposed rules and regulations for adoption on or before October 15, 2021, implementing monetary penalty provisions for facilities not in compliance with minimum staffing requirements set forth in § 23-17.5-32. (2) Monetary penalties shall be imposed quarterly and shall be based on the latest quarter for which the department has data. (3) No monetary penalty may be issued for noncompliance with the increase in the standard set forth in § 23-17.5-32(c)(ii) from January 1, 2023, to March 31, 2023. If a facility is found to be noncompliant with the increase in the standard during the period that extends from January 1, 2023, to March 31, 2023, the department shall provide a written notice identifying the staffing deficiencies and require the facility to provide a sufficiently detailed correction plan to meet the statutory minimum staffing levels. (4) Monetary penalties shall be established based on a formula that calculates on a daily basis the cost of wages and benefits for the missing staffing hours. (5) All notices of noncompliance shall include the computations used to determine noncompliance and establishing the variance between minimum staffing ratios and the department’s computations. (6) The penalty for the first offense shall be two hundred percent (200%) of the cost of wages and benefits for the missing staffing hours. The penalty shall increase to two hundred fifty percent (250%) of the cost of wages and benefits for the missing staffing hours for the second offense and three hundred percent (300%) of the cost of wages and benefits for the missing staffing hours for the third and all subsequent offenses. (7) For facilities that have an offense in three (3) consecutive quarters, EOHHS shall deny any further Medicaid Assistance payments with respect to all individuals entitled to benefits who are admitted to the facility on or after January 1, 2022, or shall freeze admissions of new residents. (c)(1) The penalty shall be imposed regardless of whether the facility has committed other violations of this chapter during the same period that the staffing offense occurred. (2) The penalty may not be waived except as provided in subsection (c)(3) of this section, but the department shall have the discretion to determine the gravity of the violation in situations where there is no more than a ten percent (10%) deviation from the staffing requirements and make appropriate adjustments to the penalty. (3) The department is granted discretion to waive the penalty when unforeseen circumstances have occurred that resulted in call-offs of scheduled staff. This provision shall be applied no more than two (2) times per calendar year. (4) Nothing in this section diminishes a facility’s right to appeal pursuant to the provisions of chapter 35 of title 42 (“administrative procedures”). (d)(1) Pursuant to rules and regulations established by the department, funds that are received from financial penalties shall be used for technical assistance or specialized direct care staff training. (2) The assessment of a penalty does not supplant the state’s investigation process or issuance of deficiencies or citations under this title. (3) A notice of noncompliance, whether or not the penalty is waived, and the penalty assessment shall be prominently posted in the nursing facility and included on the department’s website. (a) Retroactive application: (1) All fines or penalties incurred prior to January 1, 2026, are hereby forgiven, and any enforcement actions, including fines and penalties, shall commence only for violations occurring on or after January 1, 2026. (b) Compliance determination: (1) Compliance shall be determined quarterly by comparing staffing data from the Centers for Medicare and Medicaid Services’ (CMS) payroll-based journal and the facility’s daily census, as self-reported to the department. (2) Discrepancies between job titles and payroll-based journal entries shall be addressed by departmental regulations. (c) Staffing level compliance payment adjustments: (1) Facilities failing to meet minimum staffing requirements shall face a fine in the following quarter valued at three percent (3%) of the total of Medicaid reimbursements, calculated based on the most recent financial period. (d) Corrective action plan: (1) Facilities found non-compliant will receive a thirty - (30) day (30) corrective notice. (2) If compliance is not achieved within thirty (30) days, payment reductions shall be enforced. (e) Waiver provision: (1) The department shall waive fines for facilities that demonstrate high - quality care. To qualify for a waiver, a facility must meet at least one of the following criteria: (i) Substantial compliance: During the last three (3) consecutive survey cycles, the facility received no substandard quality of care/immediate jeopardy deficiencies and was not placed under compliance orders, temporary management , or quality monitoring; or (ii) Acuity criterion: A facility is considered to serve a lower-acuity resident population if its Nursing Case-Mix Index ranks in the lowest twenty-five percent (25%) of all Medicaid- participating nursing homes. The lowest twenty-five percent (25%) is determined by multiplying the current total number of Medicaid-participating nursing homes by twenty-five hundredths (0.25) and rounding up to the nearest whole number; or (iii) If the facility achieved compliance for at least seventy-five percent (75%) of operating days in the quarter. (f) Recovered funds: (1) Funds recovered through payment adjustments shall be allocated to: (i) Workforce development programs aimed at enhancing the recruitment, training, and retention of direct care staff . ; and (ii) Compliance assistance programs designed to provide technical support to underperforming facilities. (g) Implementation and oversight: (1) The department shall issue regulations to implement these provisions, with a transition period of six (6) months provided to allow facilities to meet the new requirements. (2) The department shall provide public reports on facility compliance, staffing levels, and payment adjustments on a quarterly basis. (3) Nursing home facilities shall provide a list of all licensed staff, including name, license, and home addresses, to the department upon renewal of the nursing home operator license or when there is a change in effective control of the nursing home facility. Failure to provide the required list within thirty (30) days of the renewal or change in effective control shall result in a direct monetary fine of up to one thousand dollars ($1,000) per day. (h) Audit requirements (1) EOHHS shall conduct a financial and billing audit of any Medicaid‐participating nursing home that, for four (4) consecutive quarters, has both: (i) Failed to meet the state safe-staffing standard; and (ii) Not qualified for a waiver under subsection (e) of this section § 23-17.5-33(e). ; (2) EOHHS shall initiate such audit within twelve (12) months following the end of the fourth consecutive quarter of non-compliance. (i) Public reporting. (1) Within thirty (30) days after completing any audit under subsection (f)(1), EOHHS shall publish on its website a report that includes, for each audited facility: (i) The quarter(s) audited; (ii) Key audit findings and any identified overpayments; and (iii) Amounts recovered and corrective actions taken. 23-17.5-34. Nursing staff posting requirements. (a) Each nursing facility shall post its daily direct care nurse staff levels by shift in a public place within the nursing facility that is readily accessible to and visible by residents, employees, and visitors. The posting shall be accurate to the actual number of direct care nursing staff on duty for each shift per day. The posting shall be in a format prescribed by the director, to include: (1) The number of registered nurses, licensed practical nurses, certified nursing assistants, medication technicians, licensed physical therapists, licensed occupational therapists, licensed speech-language pathologists, mental health workers who are also certified nurse assistants, and physical therapist assistants , social workers, or any nurse aide with a valid license, even if it is probationary ; (2) The number of temporary, outside agency nursing staff; (3) The resident census as of twelve o’clock (12:00) a.m.; and (4) Documentation of the use of unpaid eating assistants (if utilized by the nursing facility on that date). (b) The posting information shall be maintained on file by the nursing facility for no less than three (3) years and shall be made available to the public upon request. (c) Each nursing facility shall report the information compiled pursuant to section (a) of this section and in accordance with department of health regulations to the department of health on a quarterly basis in an electronic format prescribed by the director. The director shall make this information available to the public on a quarterly basis on the department of health website, accompanied by a written explanation to assist members of the public in interpreting the information reported pursuant to this section. (d) In addition to the daily direct nurse staffing level reports, each nursing facility shall post the following information in a legible format and in a conspicuous place readily accessible to and visible by residents, employees, and visitors of the nursing facility: (1) The minimum number of nursing facility direct care staff per shift that is required to comply with the minimum staffing level requirements in § 23-17.5-32; and (2) The telephone number or internet website that a resident, employee, or visitor of the nursing facility may use to report a suspected violation by the nursing facility of a regulatory requirement concerning staffing levels and direct patient care. (e) No nursing facility shall discharge or in any manner discriminate or retaliate against any resident of any nursing facility, or any relative, guardian, conservator, or sponsoring agency thereof or against any employee of any nursing facility or against any other person because the resident, relative, guardian, conservator, sponsoring agency, employee, or other person has filed any complaint or instituted or caused to be instituted any proceeding under this chapter, or has testified or is about to testify in any such proceeding or because of the exercise by the resident, relative, guardian, conservator, sponsoring agency, employee, or other person on behalf of himself, herself themself , or others of any right afforded by §§ 23-17.5-32, 23-17.5-33, and 23-17.5-34. Notwithstanding any other provision of law to the contrary, any nursing facility that violates any provision of this section shall: (1) Be liable to the injured party for treble damages; and (2)(i) Reinstate the employee, if the employee was terminated from employment in violation of any provision of this section; or (ii) Restore the resident to the resident’s living situation prior to such discrimination or retaliation, including the resident’s housing arrangement or other living conditions within the nursing facility, as appropriate, if the resident’s living situation was changed in violation of any provision of this section. For purposes of this section, “discriminate or retaliate” includes, but is not limited to, the discharge, demotion, suspension, or any other detrimental change in terms or conditions of employment or residency, or the threat of any such action. (f)(1) The nursing facility shall prepare an annual report showing the average daily direct care nurse staffing level for the nursing facility by shift and by category of nurse to include: (i) Registered nurses; (ii) Licensed practical nurses; (iii) Certified nursing assistants; (iv) Medication technicians; (v) Licensed physical therapists; (vi) Licensed occupational therapists; (vii) Licensed speech-language pathologists; (viii) Mental health workers who are also certified nurse assistants; (ix) Physical therapist assistants; (x) Social workers; or (xi) Any nurse aide with a valid license, even if it is probationary. (x) (xii) The use of registered and licensed practical nurses and certified nursing assistant staff from temporary placement agencies; and (xi) (xiii) The nurse and certified nurse assistant turnover rates. (2) The annual report shall be submitted with the nursing facility’s renewal application and provide data for the previous twelve (12) months and ending on or after September 30, for the year preceding the license renewal year. Annual reports shall be submitted in a format prescribed by the director. (g) The information on nurse staffing shall be reviewed as part of the nursing facility’s annual licensing survey and shall be available to the public, both in printed form and on the department’s website, by nursing facility. (h) The director of nurses may act as a charge nurse only when the nursing facility is licensed for thirty (30) beds or less. (i) Whenever the licensing agency determines, in the course of inspecting a nursing facility, that additional staffing is necessary on any residential area to provide adequate nursing care and treatment or to ensure the safety of residents, the licensing agency may require the nursing facility to provide such additional staffing and any or all of the following actions shall be taken to enforce compliance with the determination of the licensing agency: (1) The nursing facility shall be cited for a deficiency and shall be required to augment its staff within ten (10) days in accordance with the determination of the licensing agency; (2) If failure to augment staffing is cited, the nursing facility shall be required to curtail admission to the nursing facility; (3) If a continued failure to augment staffing is cited, the nursing facility shall be subjected to an immediate compliance order to increase the staffing, in accordance with § 23-1-21; or (4) The sequence and inclusion or non-inclusion of the specific sanctions may be modified in accordance with the severity of the deficiency in terms of its impact on the quality of resident care. (j) No nursing staff of any nursing facility shall be regularly scheduled for double shifts. (k) A nursing facility that fails to comply with the provisions of this chapter, or any rules or regulations adopted pursuant thereto, shall be subject to a penalty as determined by the department. SECTION 3. Section 30-25-14 of the General Laws in Chapter 30-25 entitled "Burial of Veterans" is hereby amended to read as follows: 30-25-14. Rhode Island veterans’ memorial cemetery. (a) The Rhode Island veterans’ memorial cemetery, located on the grounds of the Joseph H. Ladd school in the town of Exeter, shall be under the management and control of the director of the department of human services. The director of the department of human services shall appoint an administrator for the Rhode Island veterans’ memorial cemetery who shall be an honorably discharged veteran of the United States Armed Forces and shall have the general supervision over, and shall prescribe rules for, the government and management of the cemetery. The administrator shall make all needful rules and regulations governing the operation of the cemetery and generally may do all things necessary to ensure the successful operation thereof. The director shall promulgate rules and regulations, not inconsistent with the provisions of 38 U.S.C. § 2402, to govern the eligibility for burial in the Rhode Island veterans’ memorial cemetery. In addition to all persons eligible for burial pursuant to rules and regulations established by the director, any person who served in the army Army , navy Navy , air Air force Force , or marine Marine corps Corps of the United States for a period of not less than two (2) years and whose service was terminated honorably, shall be eligible for burial in the Rhode Island veterans’ memorial cemetery. The director shall appoint and employ all subordinate officials and persons needed for the proper management of the cemetery. National guard Guard members who are killed in the line of duty or who are honorably discharged after completion of at least six (6) years of service in the Rhode Island national National guard Guard and/or reserve Reserve and their spouse shall be eligible for interment in the Rhode Island veterans’ memorial cemetery. National guard Guard members and/or reservists Reservists who are honorably discharged after completion of at least six (6) years of service with another state, and who are a Rhode Island resident for at least two (2) consecutive years immediately prior to death, shall be eligible, along with their spouse, for interment in the Rhode Island veterans’ memorial cemetery. For the purpose of computing service under this section, honorable service in the active forces or reserves shall be considered toward the six (6) years of national National guard Guard service. The general assembly shall make an annual appropriation to the department of human services to provide for the operation and maintenance for the cemetery. The director shall may charge and collect a grave liner fee per interment of the eligible spouse and/or eligible dependents of the qualified veteran, national National guard Guard member, and/or reservist Reservist equal to the department’s cost for the grave liner. The director may promulgate rules and regulations necessary to fulfill the intent of this chapter. (b) No domestic animal shall be allowed on the grounds of the Rhode Island veterans’ memorial cemetery, whether at large or under restraint, except for seeing eye guide dogs, hearing ear signal dogs or any other service animal, as required by federal law or any personal assistance animal, as required by chapter 9.1 of title 40. Any person who violates the provisions of this section shall be subject to a fine of not less than five hundred dollars ($500). (c) The state of Rhode Island office of veterans services shall bear the cost of all tolls incurred by any motor vehicles that are part of a veteran’s funeral procession, originating from Aquidneck Island ending at the veterans’ memorial cemetery, for burial or internment. The executive director of the turnpike and bridge authority shall assist in the administration and coordination of this toll reimbursement program. SECTION 4. Section 40-5.2-20 of the General Laws in Chapter 40-5.2 entitled "The Rhode Island Works Program" is hereby amended to read as follows: 40-5.2-20. Childcare assistance — Families or assistance units eligible. [Effective January 1, 2025.] (a) The department shall provide appropriate child care to every participant who is eligible for cash assistance and who requires child care in order to meet the work requirements in accordance with this chapter. (b) Low-income child care. The department shall provide child care to all other working families with incomes at or below two hundred sixty-one percent (261%) of the federal poverty level if, and to the extent, these other families require child care in order to work at paid employment as defined in the department’s rules and regulations. The department shall also provide child care to families with incomes below two hundred sixty-one percent (261%) of the federal poverty level if, and to the extent, these families require child care to participate on a short-term basis, as defined in the department’s rules and regulations, in training, apprenticeship, internship, on-the-job training, work experience, work immersion, or other job-readiness/job-attachment program sponsored or funded by the human resource investment council (governor’s workforce board) or state agencies that are part of the coordinated program system pursuant to § 42-102-11. Effective from January 1, 2021, through June 30, 2022, the department shall also provide childcare assistance to families with incomes below one hundred eighty percent (180%) of the federal poverty level when such assistance is necessary for a member of these families to enroll or maintain enrollment in a Rhode Island public institution of higher education provided that eligibility to receive funding is capped when expenditures reach $200,000 for this provision. Effective July 1, 2022 through December 31, 2024, the department shall also provide childcare assistance to families with incomes below two hundred percent (200%) of the federal poverty level when such assistance is necessary for a member of these families to enroll or maintain enrollment in a Rhode Island public institution of higher education. Effective January 1, 2025, the department shall also provide childcare assistance to families with incomes below two hundred sixty-one percent (261%) of the federal poverty level when such assistance is necessary for a member of these families to enroll or maintain enrollment in a Rhode Island public institution of higher education. (c) No family/assistance unit shall be eligible for childcare assistance under this chapter if the combined value of its liquid resources exceeds one million dollars ($1,000,000), which corresponds to the amount permitted by the federal government under the state plan and set forth in the administrative rulemaking process by the department. Liquid resources are defined as any interest(s) in property in the form of cash or other financial instruments or accounts that are readily convertible to cash or cash equivalents. These include, but are not limited to: cash, bank, credit union, or other financial institution savings, checking, and money market accounts; certificates of deposit or other time deposits; stocks; bonds; mutual funds; and other similar financial instruments or accounts. These do not include educational savings accounts, plans, or programs; retirement accounts, plans, or programs; or accounts held jointly with another adult, not including a spouse. The department is authorized to promulgate rules and regulations to determine the ownership and source of the funds in the joint account. (d) As a condition of eligibility for childcare assistance under this chapter, the parent or caretaker relative of the family must consent to, and must cooperate with, the department in establishing paternity, and in establishing and/or enforcing child support and medical support orders for any children in the family receiving appropriate child care under this section in accordance with the applicable sections of title 15, as amended, unless the parent or caretaker relative is found to have good cause for refusing to comply with the requirements of this subsection. (e) For purposes of this section, “appropriate child care” means child care, including infant, toddler, preschool, nursery school, and school-age, that is provided by a person or organization qualified, approved, and authorized to provide the care by the state agency or agencies designated to make the determinations in accordance with the provisions set forth herein. (f)(1) Families with incomes below one hundred percent (100%) of the applicable federal poverty level guidelines shall be provided with free child care. Families with incomes greater than one hundred percent (100%) and less than two hundred percent (200%) of the applicable federal poverty guideline shall be required to pay for some portion of the child care they receive, according to a sliding-fee scale adopted by the department in the department’s rules, not to exceed seven percent (7%) of income as defined in subsection (h) of this section. (2) Families who are receiving childcare assistance and who become ineligible for childcare assistance as a result of their incomes exceeding two hundred sixty-one percent (261%) of the applicable federal poverty guidelines shall continue to be eligible for childcare assistance until their incomes exceed three hundred percent (300%) of the applicable federal poverty guidelines. To be eligible, the families must continue to pay for some portion of the child care they receive, as indicated in a sliding-fee scale adopted in the department’s rules, not to exceed seven percent (7%) of income as defined in subsection (h) of this section, and in accordance with all other eligibility standards. (g) In determining the type of child care to be provided to a family, the department shall take into account the cost of available childcare options; the suitability of the type of care available for the child; and the parent’s preference as to the type of child care. (h) For purposes of this section, “income” for families receiving cash assistance under § 40-5.2-11 means gross, earned income and unearned income, subject to the income exclusions in §§ 40-5.2-10(g)(2) and 40-5.2-10(g)(3), and income for other families shall mean gross, earned and unearned income as determined by departmental regulations. (i) The caseload estimating conference established by chapter 17 of title 35 shall forecast the expenditures for child care in accordance with the provisions of § 35-17-1. (j) In determining eligibility for childcare assistance for children of members of reserve components called to active duty during a time of conflict, the department shall freeze the family composition and the family income of the reserve component member as it was in the month prior to the month of leaving for active duty. This shall continue until the individual is officially discharged from active duty. (k) Effective from August 1, 2023, through July 31, 2025 2028 , the department shall provide funding for child care for eligible childcare educators, and childcare staff, who work at least twenty (20) hours a week in licensed childcare centers and licensed family childcare homes as defined in the department’s rules and regulations. Eligibility is limited to qualifying childcare educators and childcare staff with family incomes up to three hundred percent (300%) of the applicable federal poverty guidelines and will have no copayments. Qualifying participants may select the childcare center or family childcare home for their children. The department shall promulgate regulations necessary to implement this section, and will collect applicant and participant data to report estimated demand for state-funded child care for eligible childcare educators and childcare staff. The report shall be due annually to the governor and the general assembly by November 1 , 2024 . SECTION 5. Section 40-6-8 of the General Laws in Chapter 40-6 entitled "Public Assistance Act" is hereby amended to read as follows: 40-6-8. Supplemental nutrition assistance program (SNAP). (a) The department shall have the responsibility to administer the food stamp program for the state in compliance with the provisions of the federal Food Stamp Act of 1964, as amended, 7 U.S.C. § 2011 et seq. The supplemental nutrition assistance program (SNAP) is and shall be the new title of the program formerly known as the food stamp program. All references in the Rhode Island general laws to food stamps shall be deemed to mean, apply to, refer to, and be interpreted in accordance with the supplemental nutrition assistance program (SNAP). (b) The department is empowered and authorized to submit its plan for food stamps to the federal government, or any agency or department of it, as follows: (1) The department shall act for the state in any negotiations relative to the submission and approval of a plan, and may make any arrangement or changes in its plan not inconsistent with this chapter that may be required by the Food Stamp Act or the rules and regulations promulgated pursuant to it to obtain and retain such approval and to secure for this state the benefits of the provisions of the federal act relating to food stamps; (2) The department shall make reports to the federal government, or any agency or department of it, in the form and nature required by it, and in all respects comply with any request or direction of the federal government, or any agency or department of it, that may be necessary to assure the correctness and verification of the reports; and (3) The department shall develop a plan to streamline the application, certification, and recertification process for SNAP beneficiaries aged sixty (60) years and over. (c) The department is authorized and directed to pay one hundred percent (100%) of the state’s share of the administrative cost involved in the operation of the food stamp program. (d) No person shall be ineligible for food stamp benefits due solely to the restricted eligibility rules otherwise imposed by § 115(a)(2) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Pub. L. No. 104-193), 21 U.S.C. § 862a(a)(2), and as this section may hereafter be amended. (e) To support a fiscally responsible and high-integrity Supplemental Nutritional Nutrition Assistance Program (SNAP), the Rhode Island department of human services (DHS), in consultation with the department of administration, shall submit a plan with initial recommendations to reduce the state's SNAP Payment Error Rate (PER) to below six percent (6%), due on or before October 1, 2025, as part of the department's annual budget submission. Starting January 18, 2026, DHS shall report monthly on implementation progress and performance metrics as part of its existing legislative reporting framework. These updates shall be incorporated into DHS's monthly House Oversight RIBridges Report to ensure transparency, minimize administrative burden, and align progress tracking with the state's fiscal and policy planning cycles. Updates will include: timeliness and accuracy indicators; status of technology modernization efforts; staff training and readiness metrics; and the status of customer service enhancements and any correspondence with the federal government related to Supplemental Nutrition Assistance Program payment error rates and/or penalties. SECTION 6. Section 40-6.2-1.1 of the General Laws in Chapter 40-6.2 entitled "Child Care — State Subsidies" is hereby amended to read as follows: 40-6.2-1.1. Rates established. (a) Through June 30, 2015, subject to the payment limitations in subsection (c), the maximum reimbursement rates to be paid by the departments of human services and children, youth and families for licensed childcare centers and licensed family childcare providers shall be based on the following schedule of the 75th percentile of the 2002 weekly market rates adjusted for the average of the 75th percentile of the 2002 and the 2004 weekly market rates: Licensed Childcare Centers 75th Percentile of Weekly Market Rate Infant $182.00 Preschool $150.00 School-Age $135.00 Licensed Family Childcare Providers 75th Percentile of Weekly Market Rate Infant $150.00 Preschool $150.00 School-Age $135.00 Effective July 1, 2015, subject to the payment limitations in subsection (c), the maximum reimbursement rates to be paid by the departments of human services and children, youth and families for licensed childcare centers and licensed family childcare providers shall be based on the above schedule of the 75th percentile of the 2002 weekly market rates adjusted for the average of the 75th percentile of the 2002 and the 2004 weekly market rates. These rates shall be increased by ten dollars ($10.00) per week for infant/toddler care provided by licensed family childcare providers and license-exempt providers and then the rates for all providers for all age groups shall be increased by three percent (3%). For the fiscal year ending June 30, 2018, licensed childcare centers shall be reimbursed a maximum weekly rate of one hundred ninety-three dollars and sixty- four cents ($193.64) for infant/toddler care and one hundred sixty-one dollars and seventy-one cents ($161.71) for preschool-age children. (b) Effective July l, 2018, subject to the payment limitations in subsection (c), the maximum infant/toddler and preschool-age reimbursement rates to be paid by the departments of human services and children, youth and families for licensed childcare centers shall be implemented in a tiered manner, reflective of the quality rating the provider has achieved within the state’s quality rating system outlined in § 42-12-23.1. (1) For infant/toddler child care, tier one shall be reimbursed two and one-half percent (2.5%) above the FY 2018 weekly amount, tier two shall be reimbursed five percent (5%) above the FY 2018 weekly amount, tier three shall be reimbursed thirteen percent (13%) above the FY 2018 weekly amount, tier four shall be reimbursed twenty percent (20%) above the FY 2018 weekly amount, and tier five shall be reimbursed thirty-three percent (33%) above the FY 2018 weekly amount. (2) For preschool reimbursement rates, tier one shall be reimbursed two and one-half percent (2.5%) above the FY 2018 weekly amount, tier two shall be reimbursed five percent (5%) above the FY 2018 weekly amount, tier three shall be reimbursed ten percent (10%) above the FY 2018 weekly amount, tier four shall be reimbursed thirteen percent (13%) above the FY 2018 weekly amount, and tier five shall be reimbursed twenty-one percent (21%) above the FY 2018 weekly amount. (c) [Deleted by P.L. 2019, ch. 88, art. 13, § 4.] (d) By June 30, 2004, and biennially through June 30, 2014, the department of labor and training shall conduct an independent survey or certify an independent survey of the then-current weekly market rates for child care in Rhode Island and shall forward the weekly market rate survey to the department of human services. The next survey shall be conducted by June 30, 2016, and triennially thereafter. The departments of human services and labor and training will jointly determine the survey criteria including, but not limited to, rate categories and sub-categories. (e) In order to expand the accessibility and availability of quality child care, the department of human services is authorized to establish, by regulation, alternative or incentive rates of reimbursement for quality enhancements, innovative or specialized child care, and alternative methodologies of childcare delivery, including nontraditional delivery systems and collaborations. (f) Effective January 1, 2007, all childcare providers have the option to be paid every two (2) weeks and have the option of automatic direct deposit and/or electronic funds transfer of reimbursement payments. (g) Effective July 1, 2019, the maximum infant/toddler reimbursement rates to be paid by the departments of human services and children, youth and families for licensed family childcare providers shall be implemented in a tiered manner, reflective of the quality rating the provider has achieved within the state’s quality rating system outlined in § 42-12-23.1. Tier one shall be reimbursed two percent (2%) above the prevailing base rate for step 1 and step 2 providers, three percent (3%) above prevailing base rate for step 3 providers, and four percent (4%) above the prevailing base rate for step 4 providers; tier two shall be reimbursed five percent (5%) above the prevailing base rate; tier three shall be reimbursed eleven percent (11%) above the prevailing base rate; tier four shall be reimbursed fourteen percent (14%) above the prevailing base rate; and tier five shall be reimbursed twenty-three percent (23%) above the prevailing base rate. (h) Through December 31, 2021, the maximum reimbursement rates paid by the departments of human services, and children, youth and families to licensed childcare centers shall be consistent with the enhanced emergency rates provided as of June 1, 2021, as follows: Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Infant/Toddler $257.54 $257.54 $257.54 $257.54 $273.00 Preschool Age $195.67 $195.67 $195.67 $195.67 $260.00 School Age $200.00 $200.00 $200.00 $200.00 $245.00 The maximum reimbursement rates paid by the departments of human services, and children, youth and families to licensed family childcare providers shall be consistent with the enhanced emergency rates provided as of June 1, 2021, as follows: Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Infant/Toddler $224.43 $224.43 $224.43 $224.43 $224.43 Preschool Age $171.45 $171.45 $171.45 $171.45 $171.45 School Age $162.30 $162.30 $162.30 $162.30 $162.30 (i) Effective January 1, 2022, the maximum reimbursement rates to be paid by the departments of human services and children, youth and families for licensed childcare centers shall be implemented in a tiered manner, reflective of the quality rating the provider has achieved within the state’s quality rating system outlined in § 42-12-23.1. Maximum weekly rates shall be reimbursed as follows: Licensed Childcare Centers Tier One Tier Two Tier Three Tier Four Tier Five Infant/Toddler $236.36 $244.88 $257.15 $268.74 $284.39 Preschool $207.51 $212.27 $218.45 $223.50 $231.39 School-Age $180.38 $182.77 $185.17 $187.57 $189.97 The maximum reimbursement rates for licensed family childcare providers paid by the departments of human services, and children, youth and families is determined through collective bargaining. The maximum reimbursement rates for infant/toddler and preschool age children paid to licensed family childcare providers by both departments is implemented in a tiered manner that reflects the quality rating the provider has achieved in accordance with § 42-12-23.1. (j) Effective July 1, 2022, the maximum reimbursement rates to be paid by the departments of human services and children, youth and families for licensed childcare centers shall be implemented in a tiered manner, reflective of the quality rating the provider has achieved within the state’s quality rating system outlined in § 42-12-23.1. Maximum weekly rates shall be reimbursed as follows: Licensed Childcare Centers Tier One Tier Two Tier Three Tier Four Tier Five Infant/Toddler $265 $270 $282 $289 $300 Preschool $225 $235 $243 $250 $260 School-Age $200 $205 $220 $238 $250 (k) Effective July 1, 2024, the maximum reimbursement rates to be paid by the departments of human services and children, youth and families for licensed childcare centers shall be implemented in a tiered manner, reflective of the quality rating the provider has achieved within the state’s quality rating system outlined in § 42-12-23.1. Maximum weekly rates shall be reimbursed as follows: Licensed Childcare Centers Tier One Tier Two Tier Three Tier Four Tier Five Infant/Toddler $278 $284 $296 $303 $315 Preschool $236 $247 $255 $263 $273 School-Age $210 $215 $231 $250 $263 (l) Effective July 1, 2025, the maximum reimbursement rates to be paid by the departments of human services and children, youth and families for licensed childcare centers shall be implemented in a tiered manner, reflective of the quality rating the provider has achieved within the state’s quality rating system outlined in § 42-12-23.1. Maximum weekly rates shall be reimbursed as follows: Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Infant $334 $341 $355 $364 $378 Toddlers $278 $284 $296 $303 $315 Preschoolers $236 $247 $255 $263 $273 School Age $210 $215 $231 $250 $263 SECTION 7. Section 42-7.2-10 of the General Laws in Chapter 42-7.2 entitled "Office of Health and Human Services" is hereby amended to read as follows: 42-7.2-10. Appropriations and disbursements. (a) The general assembly shall annually appropriate such sums as it may deem necessary for the purpose of carrying out the provisions of this chapter. The state controller is hereby authorized and directed to draw his or her orders upon the general treasurer for the payment of such sum or sums, or so much thereof as may from time to time be required, upon receipt by him or her of proper vouchers approved by the secretary of the executive office of health and human services, or his or her designee. (b) For the purpose of recording federal financial participation associated with qualifying healthcare workforce development activities at the state’s public institutions of higher education, and pursuant to the Rhode Island designated state health programs (DSHP), as approved by the Centers for Medicare & Medicaid Services (CMC) October 20, 2016, in the 11-W-00242/1 amendment to Rhode Island’s section 1115 Demonstration Waiver, there is hereby established a restricted-receipt account entitled “Health System Transformation Project” in the general fund of the state and included in the budget of the office of health and human services. (c) There are hereby created within the general fund of the state and housed within the budget of the office of health and human services two restricted receipt accounts, respectively entitled “HCBS Support-ARPA” and “HCBS Admin Support-ARPA”. Amounts deposited into these accounts are equivalent to the general revenue savings generated by the enhanced federal match received on eligible home and community-based services between April 1, 2021, and March 31, 2022, allowable under Section 9817 of the American Rescue Plan Act of 2021, Pub. L. No. 117-2. Funds deposited into the “HCBS Support-ARPA” account will be used to finance the state share of newly eligible Medicaid expenditures by the office of health and human services and its sister agencies, including the department of children, youth and families, the department of health, and the department of behavioral healthcare, developmental disabilities and hospitals. Funds deposited into the “HCBS Admin Support-ARPA” account will be used to finance the state share of allowable administrative expenditures attendant to the implementation of these newly eligible Medicaid expenditures. The accounts created under this subsection shall be exempt from the indirect cost recovery provisions of § 35-4-27. (d) There is hereby created within the general fund of the state and housed within the budget of the office of health and human services a restricted receipt account entitled “Rhode Island Statewide Opioid Abatement Account” for the purpose of receiving and expending monies from settlement agreements with opioid manufacturers, pharmaceutical distributors, pharmacies, or their affiliates, as well as monies resulting from bankruptcy proceedings of the same entities. The executive office of health and human services shall deposit any revenues from such sources that are designated for opioid abatement purposes into the restricted receipt account. Funds from this account shall only be used for forward-looking opioid abatement efforts as defined and limited by any settlement agreements, state-city and town agreements, or court orders pertaining to the use of such funds. By January 1 of each calendar year, the secretary of health and human services shall report to the governor, the speaker of the house of representatives, the president of the senate, and the attorney general on the expenditures that were funded using monies from the Rhode Island statewide opioid abatement account and the amount of funds spent. The account created under this subsection shall be exempt from the indirect cost recovery provisions of § 35-4-27. No governmental entity has the authority to assert a claim against the entities with which the attorney general has entered into settlement agreements concerning the manufacturing, marketing, distributing, or selling of opioids that are the subject of the Rhode Island Memorandum of Understanding Between the State and Cities and Towns Receiving Opioid Settlement Funds executed by every city and town and the attorney general and wherein every city and town agreed to release all such claims against these settling entities, and any amendment thereto. Governmental entity means any state or local governmental entity or sub-entity and includes, but is not limited to, school districts, fire districts, and any other such districts. The claims that shall not be asserted are the released claims, as that term is defined in the settlement agreements executed by the attorney general, or, if not defined therein, the claims sought to be released in such settlement agreements. (e) There is hereby created within the general fund of the state and housed within the budget of the executive office of health and human services a restricted receipt account, respectively entitled "Minimum Staffing Level Compliance and Enforcement". Funds deposited into the account will be used for workforce development and compliance assistance programs as included in § 23- 17.5-33. SECTION 8. Section 42-7.4-3 of the General Laws in Chapter 42-7.4 entitled "The Healthcare Services Funding Plan Act" is hereby amended to read as follows: 42-7.4-3. Imposition of healthcare services funding contribution. [As enacted in 2014.] (a) Each insurer is required to pay the healthcare services funding contribution for each contribution enrollee of the insurer at the time the contribution is calculated and paid, at the rate set forth in this section. (1) Beginning January 1, 2016, the secretary shall set the healthcare services funding contribution each fiscal year in an amount equal to: (i) The child immunization funding requirement described in § 23-1-46; plus (ii) The adult immunization funding requirement described in § 23-1- 46; plus (iii) The children’s health services funding requirement described in § 42-12-29; and all as divided by (iv) The number of contribution enrollees of all insurers. (2) The contribution set forth herein shall be in addition to any other fees or assessments upon the insurer allowable by law. (b) The contribution shall be paid by the insurer; provided, however, a person providing health benefits coverage on a self-insurance basis that uses the services of a third-party administrator shall not be required to make a contribution for a contribution enrollee where the contribution on that enrollee has been or will be made by the third-party administrator. (c) Beginning calendar year 2026, in addition to the assessment collection pursuant to subsection (a), there shall be an additional amount assessed pursuant to (i) and (ii), to support primary care and other critical healthcare programs totaling thirty million dollars ($30,000,000), which shall be deposited as general revenues. (c) The secretary shall create a process to facilitate the transition to the healthcare services funding contribution method that: (i) assures adequate funding beginning July 1, 2016, (ii) reflects that funding via the healthcare services funding contribution method initially will be for only a portion of the state’s fiscal year, and (iii) avoids duplicate liability for any insurer that made a payment under the premium assessment method in effect prior to January 1, 2016, for a period for which it would also be liable for a contribution under the healthcare services funding contribution method as described in this chapter. 42-7.4-3. Imposition of healthcare services funding contribution. [As amended by P.L. 2024, ch. 423, § 1; See Compiler’s Note.] (a) Each insurer is required to pay the healthcare services funding contribution for each contribution enrollee of the insurer at the time the contribution is calculated and paid, at the rate set forth in this section. (1) Beginning July 1, 2024, the secretary shall set the healthcare services funding contribution each fiscal year in an amount equal to: (i) The child immunization funding requirement described in § 23-1-46; plus (ii) The adult immunization funding requirement described in § 23-1- 46; plus (iii) The children’s health services funding requirement described in § 42-12-29; plus (iv) The psychiatry resource network funding requirement described in § 23-1-46.1 and all as divided by; (v) The number of contribution enrollees of all insurers. (2) The contribution set forth herein shall be in addition to any other fees or assessments upon the insurer allowable by law. (b) The contribution shall be paid by the insurer; provided, however, a person providing health benefits coverage on a self-insurance basis that uses the services of a third-party administrator shall not be required to make a contribution for a contribution enrollee where the contribution on that enrollee has been or will be made by the third-party administrator. (c) The secretary shall create a process to facilitate the transition to the healthcare services funding contribution method that: (i) assures adequate funding beginning July 1, 2016, (ii) reflects that funding via the healthcare services funding contribution method initially will be for only a portion of the state’s fiscal year, and (iii) avoids duplicate liability for any insurer that made a payment under the premium assessment method in effect prior to January 1, 2016, for a period for which it would also be liable for a contribution under the healthcare services funding contribution method as described in this chapter. SECTION 9. This article shall take effect upon passage.