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[House Report 105-23]
[From the U.S. Government Publishing Office]

105th Congress                                            Rept.  105-23
                        HOUSE OF REPRESENTATIVES

 1st Session                                                     Part 1
_______________________________________________________________________

 
      WAIVER OF MEDICARE AND MEDICAID NURSING FACILITY PROHIBITION

                                _______
                                

                 March 13, 1997.--Ordered to be printed

_______________________________________________________________________

    Mr. Archer, from the Committee on Ways and Means, submitted the 
                               following

                              R E P O R T

                        [To accompany H.R. 968]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Ways and Means, to whom was referred the 
bill (H.R. 968) to amend title XVIII and XIX of the Social 
Security Act to permit a waiver of the prohibition of offering 
nurse aide training and competency evaluation programs in 
certain nursing facilities, having considered the same, report 
favorably thereon with amendments and recommend that the bill 
as amended do pass.

                                CONTENTS

                                                                   Page
 I. Introduction......................................................2
        A. Purpose and Summary...................................     2
        B. Background and Need for Legislation...................     2
        C. Legislative History...................................     2
II. Explanation of the Bill...........................................3
III.Vote of the Committee.............................................3

IV. Budgets Effects of the Bill.......................................4
        A. Committee Estimate of Budgetary Effects...............     4
        B. Statement Regarding New Budget Authority and Tax 
          Expenditures...........................................     4
        C. Cost Estimate Prepared by the Congressional Budget 
          Office.................................................     4
 V. Other Matters To Be Discussed Under the Rules of the House........5
        A. Committee Oversight Findings and Recommendations......     5
        B. Summary of Findings and Recommendations of the 
          Government Operations Committee........................     5
        C. Constitutional Authority..............................     5
VI. Changes in Existing Law Made by the Bill, as Reported.............5

    The amendments (stated in terms of the page and line 
numbers of the introduced bill) are as follows:
    Page 2, line 12, strike ``(iii)'' and insert ``(iii)(I)''.
    Page 2, line 14, insert ``(or skilled nursing facility for 
purposes of title XVIII)'' after ``nursing facility''.

                            I. Introduction

                         a. purpose and summary

    H.R. 968 amends title XVIII and title XIX of the Social 
Security Act to permit a waiver of the prohibition on offering 
nurse aide training and competency evaluation programs in 
certain nursing facilities. This measure permits a State to 
waive the current prohibition if the State: (1) determines that 
there is no other program offered within a reasonable distance 
of the facility; (2) assures, through an oversight effort, that 
an adequate environment exists for operating the program in the 
facility; and, (3) provides notice of such determination to the 
State long-term care ombudsman.

                 b. background and need for legislation

    Under current law, a nursing facility may lose its ability 
to offer facility-based nurse aide training and competency 
evaluation programs for reasons that may be unrelated to the 
quality of its training activities. This unintended consequence 
of current law arises from instances in which a deficiency may 
exist, but may be unrelated to the nurse aide training and 
evaluation programs, and is being or has been corrected. As a 
result, nursing facilities, particularly those in rural 
communities, face difficulties filling staff positions because 
they are prevented from conducting on-site nurse aide training 
and evaluation programs.
    This measure would revise current law to permit the 
continuation of nurse aide training and competency evaluation 
programs in affected facilities under certain circumstances. In 
order for a facility to continue its training and evaluation 
programs, the State in which the facility is located would have 
to make a determination that no similar program is in existence 
within a reasonable distance of the facility, conduct oversight 
activities to ensure that an adequate environment exists for 
operating the program in the facility, and provide notice of 
such determination to the State long-term care ombudsman. The 
Committee and the Administration agree that these training 
programs should continue under certain circumstances.

                         c. legislative history

Committee bill

    H.R. 968 was introduced March 6, 1997 by Mr. Ehrlich of 
Maryland, et al., and referred to the Committee on Ways and 
Means, and in addition, to the Committee on Commerce. The bill, 
as introduced, contained a provision to permit a waiver of the 
prohibition of offering nurse aide training and competency 
evaluation programs in certain nursing facilities. The 
Committee on Ways and Means considered the bill on March 12, 
1997, and ordered the bill favorably reported, without 
amendment, by voice vote, with a quorum present.

Legislative hearing

    The Committee of Ways and Means held a hearing on Medicare 
payment and policy issues related to skilled nursing facilities 
on March 4, 1997.

                      II. Explanation of the Bill

permit a waiver of the prohibition of offering nurse aide training and 
competency evaluation programs in certain nursing facilities (sec. 1 of 
               the bill and sec. 4201(f)(1) of obra 1987)

Present law

    Under Medicare and Medicaid, nursing facilities must comply 
with federal and state laws regarding nurse aide training and 
competency evaluation programs. OBRA 1987 required the 
Secretary of Health and Human Services to establish and enforce 
such requirements. As such, if a nursing facility has been 
subject to an extended (or partial extended) survey, it is 
prohibited from operating a nurse aide training and competency 
evaluation program.

Explanation of provision

    The provision would permit a waiver of the prohibition of 
offering nurse aide training and competency evaluation programs 
in certain nursing facilities if the State: (1) determines 
there is no other training program within a reasonable distance 
of the facility; (2) assures that an adequate environment 
exists for operating the program in the facility; and, (3) 
provides notice to the State long-term care ombudsman.

Reasons for change

    Nursing facilities in rural areas face difficulties 
recruiting nurse aides; many rural areas have no such training 
facilities, making it difficult to recruit nurse aides which 
may affect patient care. Nursing home providers, particularly 
those located in rural communities, have raised concerns about 
the prohibition on nurse aide training and competency 
evaluation programs in a facility as the result of being 
subject to an extended (or partial extended) survey.

Effective date

    The provision is effective upon enactment.

                       III. Vote of the Committee

    In compliance with clause 2(l)(2)(B) of rule XI of the 
Rules of the House of Representatives, the following statement 
is made concerning the vote of the Committee in its 
consideration of the bill, H.R. 968:

                       MOTION TO REPORT THE BILL

    The bill, H.R. 968, was ordered favorably reported by voice 
vote on March 12, 1997, with a quorum present.

                     IV. Budget Effects of the Bill

               A. Committee Estimate of Budgetary Effects

    In compliance with clause 7(a) of rule XIII of the Rules of 
the House of Representatives, the following statement is made 
concerning the effects on the budget of this bill, H.R. 968, as 
reported: The Committee agrees with the estimate prepared by 
CBO which is included below.

    B. STATEMENT REGARDING NEW BUDGET AUTHORITY AND TAX EXPENDITURES

    In compliance with subdivision (B) of clause 2(l)(3) rule 
XI of the Rules of the House of Representatives, the Committee 
states that the provisions of H.R. 968 do not involve any new 
budget authority, or any increase or decrease in revenues or 
tax expenditures.

      C. COST ESTIMATE PREPARED BY THE CONGRESSIONAL BUDGET OFFICE

    In compliance with subdivision (C) of clause 2(l)(3) of 
rule XI of the Rules of the House of Representatives, requiring 
a cost estimate prepared by the Congressional Budget Office, 
the following report prepared by CBO is provided.

                                     U.S. Congress,
                               Congressional Budget Office,
                                    Washington, DC, March 13, 1997.
Hon. Bill Archer,
Chairman, Committee on Ways and Means,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 968, a bill to 
permit a waiver of the prohibition of offering nurse aide 
training and competency evaluation programs in certain nursing 
facilities.
    If you wish for further details on this estimate, we will 
be pleased to provide them. The CBO staff contact is Robin 
Rudowitz.
            Sincerely,
                                         June E. O'Neill, Director.
    Enclosure.

H.R. 968--A bill to permit a waiver of the prohibition of offering 
        nurse aide training and competency evaluation programs in 
        certain nursing facilities

    CBO estimates that enactment of this bill would have no 
budgetary impact.
    Nursing facilities must meet certain requirements to be 
certified for payment by the Medicare and Medicaid programs. 
Among these are provisions included in the Omnibus Budget 
Reconciliation Act of 1987 that require nursing facilities to 
conduct nurse aid training and competency evaluation programs. 
However, the Secretary can approve such programs at nursing 
facilities only under certain conditions. In rural areas where 
there are no nearby training programs, the bill would allow the 
Secretary to waive some of the restrictions so that a training 
program could be conducted at a nursing facility as long as the 
program was not conducted by the nursing facility.
    This bill contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act of 1995 
(UMRA) and would impose no costs on state, local, or tribal 
governments.
    The CBO staff contact for the estimate is Robin Rudowitz. 
This estimate was approved by Paul N. Van de Water, Assistant 
Director for Budget Analysis.

     V. Other Matters To Be Discussed Under the Rules of the House

          A. COMMITTEE OVERSIGHT FINDINGS AND RECOMMENDATIONS

     With respect to subdivision (A) of clause 2(l)(3) of rule 
XI of the Rules of the House of Representatives (relating to 
oversight findings), the Committee advises that it was as a 
result of its oversight activities with respect to the Medicare 
program that the Committee concluded that it is appropriate to 
enact the provision contained in the bill as reported.

    B. SUMMARY OF FINDINGS AND RECOMMENDATIONS OF THE COMMITTEE ON 
                    GOVERNMENT REFORM AND OVERSIGHT

    With respect to subdivision (D) of clause 2(l)(3) of rule 
XI of the Rules of the House of Representatives (relating to 
oversight findings), the Committee advises that no oversight 
findings or recommendations have been submitted to this 
Committee by the Committee on Government Reform and Oversight 
with respect to the provisions contained in this bill.

                 C. CONSTITUTIONAL AUTHORITY STATEMENT

    With respect to clause 2(l)(4) of rule XI of the Rules of 
the House of Representatives, relating to Constitutional 
Authority, the Committee states that the Committee's action in 
reporting the bill is derived from Article I of the 
Constitution, Section 8 (``The Congress shall have power to lay 
and collect taxes, duties, imposts and excises, to pay the 
debts and to provide for * * * the general Welfare of the 
United States * * *'').

       VI. Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3 of rule XIII of the Rules of the 
House of Representatives, changes in existing law made by the 
bill, as reported, are shown as follows (new matter is printed 
in italic and existing law in which no change is proposed is 
shown in roman):

                         THE SOCIAL SECURITY ACT

          * * * * * * *

        TITLE XVIII--HEALTH INSURANCE FOR THE AGED AND DISABLED

          * * * * * * *

  requirements for, and assuring quality of care in, skilled nursing 
                               facilities

  Sec. 1819. (a) * * *
          * * * * * * *
  (f) Responsibilities of Secretary Relating to Skilled Nursing 
Facility Requirements.--
          (1) General responsibility.--It is the duty and 
        responsibility of the Secretary to assure that 
        requirements which govern the provision of care in 
        skilled nursing facilities under this title, and the 
        enforcement of such requirements, are adequate to 
        protect the health, safety, welfare, and rights of 
        residents and to promote the effective and efficient 
        use of public moneys.
          (2) Requirements for nurse aide training and 
        competency evaluation programs and for nurse aide 
        competency evaluation programs.--
                  (A) * * *
                  (B) Approval of certain programs.--Such 
                requirements--
                          (i) * * *
          * * * * * * *
                          (iii) subject to subparagraph (C), 
                        shall prohibit approval of such a 
                        program--
                                  (I) * * *
          * * * * * * *
                  (C) Waiver authorized.--Clause (iii)(I) of 
                subparagraph (B) shall not apply to a program 
                offered in (but not by) a nursing facility (or 
                skilled nursing facility for purposes of title 
                XVIII) in a State if the State--
                          (i) determines that there is no other 
                        such program offered within a 
                        reasonable distance of the facility,
                          (ii) assures, through an oversight 
                        effort, that an adequate environment 
                        exists for operating the program in the 
                        facility, and
                          (iii) provides notice of such 
                        determination and assurances to the 
                        State long-term care ombudsman.
          * * * * * * *

      TITLE XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

          * * * * * * *

                  requirements for nursing facilities

  Sec. 1919. (a) * * *
          * * * * * * *
  (f) Responsibilities of Secretary Relating to Nursing 
Facility Requirements.--
          (1) General responsibility.--It is the duty and 
        responsibility of the Secretary to assure that 
        requirements which govern the provision of care in 
        nursing facilities under State plans approved under 
        this title, and the enforcement of such requirements, 
        are adequate to protect the health, safety, welfare, 
        and rights of residents and to promote the effective 
        and efficient use of public moneys.
          (2) Requirements for nurse aide training and 
        competency evaluation programs and for nurse aide 
        competency evaluation programs.--
                  (A) * * *
                  (B) Approval of certain programs.--Such 
                requirements--
                          (i) * * *
          * * * * * * *
                          (iii) subject to subparagraph (C), 
                        shall prohibit approval of such a 
                        program--
                                  (I) * * *
          * * * * * * *
                  (C) Waiver authorized.--Clause (iii)(I) of 
                subparagraph (B) shall not apply to a program 
                offered in (but not by) a nursing facility (or 
                skilled nursing facility for purposes of title 
                XVIII) in a State if the State--
                          (i) determines that there is no other 
                        such program offered within a 
                        reasonable distance of the facility,
                          (ii) assures, through an oversight 
                        effort, that an adequate environment 
                        exists for operating the program in the 
                        facility, and
                          (iii) provides notice of such 
                        determination and assurances to the 
                        State long-term care ombudsman.
          * * * * * * *

                                
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