I 

108TH CONGRESS 

1ST SESSION H. R. 3355

To amend titles XVIII and XIX of the Social Security Act to establish 

minimum requirements for nurse staffing in nursing facilities receiving 

payments under the Medicare or Medicaid Program. 

IN THE HOUSE OF REPRESENTATIVES 

OCTOBER 21, 2003

Mr. WAXMAN (for himself, Mr. DINGELL, Mr. STARK, Mr. BROWN of Ohio, 

Mr. FROST, Mr. GEORGE MILLER of California, Ms. SCHAKOWSKY, Mr. 

CARSON of Oklahoma, Mr. RODRIGUEZ, Mr. MARKEY, Ms. NORTON, Ms. 

KAPTUR, Mr. SANDERS, Mr. HOEFFEL, Mrs. MALONEY, Mr. GRIJALVA, 

Mr. HINCHEY, Mr. UDALL of New Mexico, Mr. ACEVEDO-VILA ́, Mr. 

KUCINICH, Mr. MOORE, Mr. LANTOS, Ms. CORRINE BROWN of Florida, 

Mr. THOMPSON of Mississippi, Mr. BERMAN, Mr. WEXLER, Mr. EVANS, 

Ms. ROYBAL-ALLARD, Mr. KILDEE, Ms. BALDWIN, Mrs. CAPPS, Ms. 

SOLIS, Mr. STUPAK, Mr. KLECZKA, Mr. BACA, Mr. MCGOVERN, Mr. 

HOLT, Mr. PALLONE, Ms. ESHOO, Mr. BRADY of Pennsylvania, Mr. 

CLAY, and Mr. MCDERMOTT) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to 

the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions 

as fall within the jurisdiction of the committee concerned 

A BILL

To amend titles XVIII and XIX of the Social Security Act 

to establish minimum requirements for nurse staffing 

in nursing facilities receiving payments under the Medicare or Medicaid Program.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,
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1 SECTION 1. SHORT TITLE; PURPOSE. 

2 (a) SHORT TITLE.—This Act may be cited as the 

3 ‘‘Nursing Home Staffing Act of 2003’’. 

4 (b) PURPOSE.—The purpose of this Act is to improve 

5 the quality of care received by residents of nursing facili6 ties through the implementation of the minimum nurse 

7 staffing levels identified by the Secretary of Health and 

8 Human Services in a report to Congress submitted on 

9 March 21, 2002. 

10 SEC. 2. IMPLEMENTATION OF NURSE STAFFING STAND11 ARDS. 

12 (a) IN GENERAL.—Sections 1819(b)(4) and 

13 1919(b)(4) of the Social Security Act (42 U.S.C. 1395i–

14 3(b)(4); 1396r(b)(4)) are each amended by adding at the 

15 end the following new subparagraph: 

16 ‘‘(D) MINIMUM STAFFING REQUIRE17 MENTS.—

18 ‘‘(i) DEADLINE FOR COMPLIANCE

19 WITH MINIMUM STANDARDS.—With respect 

20 to facility services provided after the date 

21 that is the end of the 2-year period begin22 ning on the date of the enactment of this 

23 subparagraph, a facility shall comply with 

24 the minimum staffing levels promulgated 

25 by the Secretary under clause (ii). 

26 ‘‘(ii) FINAL REGULATIONS.—
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1 ‘‘(I) IN GENERAL.—Not later 

2 than 1 year after the date of the en3 actment of this subparagraph, and 

4 consistent with the provisions of this 

5 clause, the Secretary shall promulgate 

6 standards for minimum staffing levels 

7 for facilities. Such standards shall 

8 provide for sufficient staffing levels 

9 during day, evening, and night shifts 

10 to ensure that residents of nursing fa11 cilities receive the level of care nec12 essary to meet the objectives of sub13 section (b)(2), and shall provide for 

14 appropriate adjustments to account 

15 for resident case mix. 

16 ‘‘(II) MINIMUM STANDARDS.—

17 Subject to subclause (III), standards 

18 promulgated under subclause (I) shall 

19 be, at a minimum, the HHS minimum 

20 nurse staffing ratios (as defined in 

21 clause (iii)). 

22 ‘‘(III) AUTHORITY TO PHASE IN

23 FACILITY COMPLIANCE WITH STAND24 ARDS.—If the Secretary determines 

25 that compliance with the HHS min-
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1 imum nurse staffing ratios is not fea2 sible for nursing facilities by the end 

3 of the 2-year period applicable under 

4 clause (i), the Secretary may delay the 

5 implementation of the HHS minimum 

6 nurse staffing ratios until the date 

7 that is the end of the 5-year period 

8 that begins on the date of the enact9 ment of this subparagraph. If the Sec10 retary delays implementation of the 

11 HHS minimum nurse staffing ratios 

12 under the previous sentence, the Sec13 retary shall phase in over such 5-year 

14 period alternative minimum staffing 

15 standards that gradually increase in 

16 each of the years of the phase-in until 

17 the such standards meet the HHS 

18 minimum nurse staffing ratios. 

19 ‘‘(IV) COUNTING.—In deter20 mining compliance with the staffing 

21 levels under this subparagraph, an in22 dividual may not be counted while 

23 performing services that are not direct 

24 nursing care, such as administrative 

25 services, food preparation, house-
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1 keeping, laundry, maintenance serv2 ices, or other activities that are not 

3 direct nursing care. 

4 ‘‘(iii) HHS MINIMUM NURSE STAFF5 ING RATIOS.—The term ‘HHS minimum 

6 nurse staffing ratios’ means the minimum 

7 staffing levels identified in the report to 

8 Congress entitled ‘Appropriateness of Min9 imum Nurse Staffing Ratios in Nursing 

10 Homes, Report to Congress: Phase II 

11 Final’ submitted by the Secretary on 

12 March 21, 2002, which require—

13 ‘‘(I) from 2.4 to 2.8 hours of 

14 care per resident per day by a cer15 tified nurse aide, and 

16 ‘‘(II) from 1.15 to 1.3 hours of 

17 care per resident per day by a licensed 

18 practical nurse, a licensed vocational 

19 nurse, or a registered nurse, of which 

20 from 0.55 to 0.75 hours of care per 

21 resident per day shall be provided by 

22 a registered nurse. 

23 ‘‘(iv) CONSTRUCTION.—

24 ‘‘(I) NONPREEMPTION.—Nothing 

25 in this subparagraph shall be con-
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1 strued as prohibiting the Secretary or 

2 a State (in the case of title XIX) from 

3 imposing higher minimum staffing 

4 levels on facilities than those imposed 

5 under this subparagraph. 

6 ‘‘(II) MINIMUM STANDARDS

7 ONLY.—Compliance with the staffing 

8 requirements imposed under this sub9 paragraph alone shall not be con10 strued as complying with the require11 ment under paragraph (2) to provide 

12 services to attain or maintain the 

13 highest practicable physical, mental, 

14 and psychosocial well-being of each 

15 resident. 

16 ‘‘(III) SUPPLEMENTARY RE17 QUIREMENTS.—The staffing require18 ments of this subparagraph are in ad19 dition to the requirements of subpara20 graph (C).’’. 

21 (b) POSTING OF STAFFING INFORMATION.—

22 (1) IN GENERAL.—The first sentence of sub23 paragraph (A) of sections 1819(b)(8) and 

24 1919(b)(8) of the Social Security Act (42 U.S.C. 

25 1395i–3(b)(8); 1396r(b)(8)) are each amended by 
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1 inserting before the period the following: ‘‘, a de2 scription of the minimum staffing requirements 

3 under paragraph (4)(D), and the average number of 

4 hours of nursing care that residents of the facility 

5 have received for each of the four previous calendar 

6 quarters’’. 

7 (2) REPORTS.—Such sections are each amended 

8 by adding at the end the following new subpara9 graph: 

10 ‘‘(C) REPORTS OF STAFFING DATA.—A fa11 cility shall maintain records on nurse staffing, 

12 and shall submit such reports of such records 

13 to the Secretary as the Secretary may require 

14 for the administration and enforcement of this 

15 section. Such records shall be reviewed for accu16 racy as part of a standard survey required 

17 under subsection (g)(2)(A).’’. 

18 SEC. 3. INCREASED RESOURCES. 

19 (a) REINSTITUTION OF BOREN AMENDMENT PAY20 MENT METHODOLOGY.—

21 (1) IN GENERAL.—Section 1902(a)(13) of the 

22 Social Security Act (42 U.S.C. 1396a(a)(13)) is 

23 amended to read as follows: 

24 ‘‘(13) provide for payment of services through 

25 the use of rates determined pursuant to the criteria 
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1 under this paragraph as in effect on August 1, 

2 1997;’’. 

3 (2) ESTABLISHMENT OF SAFE HARBOR

4 RATES.—Section 1902 of such Act (42 U.S.C. 

5 1396a) is amended by adding at the end the fol6 lowing: ‘‘The Secretary may, by regulation, promul7 gate standards or methodologies for determining 

8 rates that comply with paragraph (13), and a State 

9 that pays rates that meet such standards or meth10 odologies is deemed to be in compliance with para11 graph (13).’’. 

12 (3) EFFECTIVE DATE.—The amendment made 

13 by this subsection shall apply to services furnished 

14 on or after the date that is one year after the date 

15 of the enactment of this Act. 

16 (b) PERMANENT 1.5 PERCENT INCREASE OF MED17 ICAID FMAP BEGINNING WITH FISCAL YEAR 2004.—

18 Section 1905(b) of the Social Security Act (42 U.S.C. 

19 1396d(b)) is amended by adding at the end the following: 

20 ‘‘With respect to calendar quarters beginning after Octo21 ber 1, 2003, the Federal medical assistance percentage for 

22 a State determined under the first sentence shall be in23 creased by 1.50 percentage points.’’. 

24 (c) FINANCIAL ACCOUNTABILITY.—
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1 (1) IN GENERAL.—Sections 1819(g)(2) and 

2 1919(g)(2) of the Social Security Act (42 U.S.C. 

3 1395i–3(g)(2); 1396r(g)(2)) are each amended—

4 (A) by redesignating subparagraphs (C), 

5 (D), and (E) as subparagraphs (D), (E), and 

6 (F); and 

7 (B) by inserting after subparagraph (B) 

8 the following new subparagraph: 

9 ‘‘(C) FINANCIAL ACCOUNTABILITY.—A 

10 standard or an extended survey may include an 

11 examination of the financial records of a facility 

12 to determine whether payments made to the fa13 cility under this section for services furnished to 

14 residents are being used in a manner consistent 

15 with this section.’’. 

16 (2) COMPOSITION OF MULTIDISCIPLINARY

17 TEAM.—Sections 1819(g)(2)(E)(i) and 

18 1919(g)(2)(E)(i) of the Social Security Act (42 

19 U.S.C. 1395i–3(g)(2)(E)(i); 1396r(g)(2)(E)(i)) are 

20 each amended by inserting after the period the fol21 lowing: ‘‘This multidisciplinary team may include 

22 professionals trained in financial accounting and au23 diting.’’
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1 (3) EFFECTIVE DATE.—The amendments made 

2 by paragraph (1) shall apply to surveys conducted 

3 on or after the date of the enactment of this Act.

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