```

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

105th Congress                                             Rept. 105-23
                        HOUSE OF REPRESENTATIVES

 1st Session                                                     Part 2
_______________________________________________________________________

 
      WAIVER OF MEDICARE AND MEDICAID NURSING FACILITY PROHIBITION

                                _______
                                

 March 18, 1997.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

_______________________________________________________________________

  Mr. Bliley, from the Committee on Commerce, 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 Commerce, 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
Amendment........................................................     2
Purpose and Summary..............................................     2
Background and Need for Legislation..............................     2
Hearings.........................................................     2
Committee Consideration..........................................     2
Rollcall Votes...................................................     3
Committee Oversight Findings.....................................     3
Committee on Government Reform and Oversight.....................     3
New Budget Authority and Tax Expenditures........................     3
Committee Cost Estimate..........................................     3
Congressional Budget Office Estimate.............................     3
Federal Mandates Statement.......................................     4
Advisory Committee Statement.....................................     4
Constitutional Authority Statement...............................     4
Applicability to Legislative Branch..............................     5
Section-by-Section Analysis of the Legislation...................     5
Changes in Existing Law Made by the Bill, as Reported............     5

                               Amendment

    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''.

                          Purpose and Summary

    H.R. 968 amends Title XVIII and Title XIX of the Social 
Security Act to permit a waiver of the prohibition of offering 
nurse aide training and competency evaluation programs in 
certain facilities. This measure permits a State to waive the 
current prohibition if the State: (1) determines that there is 
no other such 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.

                  Background and Need for Legislation

    Under existing Federal law, a nursing facility may lose its 
ability to offer facility-based nurse aide training and 
competency evaluation programs for reasons that are unrelated 
to the quality of the program itself. This unintended 
consequence of current law arises from instances where some 
form of operational deficiency may exist, even though such 
deficiency is 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, are prevented from conducting the training and 
evaluation that is integral to the provision of quality nursing 
care and the prevention of a staffing void.
    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 it 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.

                                Hearings

    The Committee on Commerce has not held hearings on the 
legislation.

                        Committee Consideration

    On March 12, 1997, the Subcommittee on Health and 
Environment met in open markup session and, by unanimous 
consent, a quorum being present, approved H.R. 968 for Full 
Committee consideration, without amendment.
    On March 13, 1997, the Full Committee met in open markup 
session and ordered H.R. 968 reported to the House, without 
amendment, by a voice vote.

                             Rollcall Votes

    Clause 2(l)(2)(B) of rule XI of the Rules of the House 
requires the Committee to list the recorded votes on the motion 
to report legislation and on amendments thereto. There were no 
recorded votes taken in connection with ordering H.R. 968 
reported. A motion by Mr. Bliley to order H.R. 968 reported to 
the House, without amendment, was agreed to by a voice vote, a 
quorum being present.

                      Committee Oversight Findings

    Pursuant to clause 2(l)(3)(A) of rule XI of the Rules of 
the House of Representatives, the Committee has not held 
oversight or legislative hearings on this legislation.

              Committee on Government Reform and Oversight

    Pursuant to clause 2(l)(3)(D) of rule XI of the Rules of 
the House of Representatives, no oversight findings have been 
submitted to the Committee by the Committee on Government 
Reform and Oversight.

               New Budget Authority and Tax Expenditures

    In compliance with clause 2(l)(3)(B) of rule XI of the 
Rules of the House of Representatives, the Committee finds that 
H.R. 968, a bill to amend the Social Security Act to permit a 
waiver of the prohibition of offering nurse aide training and 
competency evaluation programs in certain facilities, would 
result in no new or increased budget authority or tax 
expenditures or revenues.

                        Committee Cost Estimate

    The Committee adopts as its own the cost estimate prepared 
by the Director of the Congressional Budget Office pursuant to 
section 403 of the Congressional Budget Act of 1974.

                  Congressional Budget Office Estimate

    Pursuant to clause 2(l)(3)(C) of rule XI of the Rules of 
the House of Representatives, the following is the cost 
estimate provided by the Congressional Budget Office pursuant 
to section 403 of the Congressional Budget Act of 1974:

                                     U.S. Congress,
                               Congressional Budget Office,
                                    Washington, DC, March 14, 1997.
Hon. Tom Bliley,
Chairman, Committee on Commerce,
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 aide 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.
            Previous CBO estimate
    An essentially similar version of H.R. 968 was ordered 
reported by the Committee on Ways and Means on March 12, 1997. 
CBO estimated that enactment of the bill would have no 
budgetary impact.

                       Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates prepared by the Director of the Congressional Budget 
Office pursuant to section 423 of the Unfunded Mandates Reform 
Act.

                      Advisory Committee Statement

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act were created by this 
legislation.

                   Constitutional Authority Statement

    Pursuant to clause 2(l)(4) of rule XI of the Rules of the 
House of Representatives, the Committee finds that the 
Constitutional authority for this legislation is provided in 
Article I, section 8, clause 3, which grants Congress the power 
to regulate commerce with foreign nations, among the several 
States, and with the Indian tribes.

                  Applicability to Legislative Branch

    The Committee finds that the legislation does not relate to 
the terms and conditions of employment or access to public 
services or accommodations within the meaning of section 
102(b)(3) of the Congressional Accountability Act.

             Section-by-Section Analysis of the Legislation

  Section 1. Permitting Waiver of Prohibition of Offering Nurse Aide 
   Training and Competency Evaluation Programs in Certain Facilities

    Section 1 of the bill amends section 1819(f)(2) and section 
1919(f)(2) of the Social Security Act to authorize a waiver of 
the prohibition of offering nurse aide training and competency 
evaluation programs in certain facilities upon a State 
determination that no similar program is in existence within a 
reasonable distance of the facility, an adequate environment 
exists for operating the program in the facility, and the State 
long-term care ombudsman has been notified of the above.

         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.
          * * * * * * *

                                

```