I

106TH CONGRESS

2D SESSION H. R. 5243

To establish a program to provide grants to States to test innovative ways

to increase nursing home staff levels, reduce turnover, and improve

quality of care for residents in nursing homes, and for other purposes.

IN THE HOUSE OF REPRESENTATIVES

SEPTEMBER 21, 2000

Mr. HOLT (for himself, Mr. GEPHARDT, Mr. WAXMAN, and Mr. STARK) introduced the following bill; which was referred to the Committee on 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 establish a program to provide grants to States to test

innovative ways to increase nursing home staff levels,

reduce turnover, and improve quality of care for residents in nursing homes, and for other purposes.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE; REFERENCES IN ACT.

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

5 ‘‘Nursing Home Staffing and Quality Improvement Act of

6 2000’’.
2

HR 5243 IH

1 (b) REFERENCES.—Except where otherwise specifi2 cally provided, references in this Act shall be considered

3 to be made to the Social Security Act, or to a section or

4 other provision thereof, and references to the ‘‘Secretary’’

5 shall be considered to be made to the Secretary of Health

6 and Human Services.

7 SEC. 2. GRANTS TO STATES FOR IMPROVEMENTS IN NURS8 ING HOME STAFFING AND QUALITY.

9 (a) SECRETARY’S AUTHORITY TO AWARD GRANTS.—

10 The Secretary shall establish a program of competitive

11 grants to States, in accordance with the provisions of this

12 section, for the purpose of improving the quality of care

13 furnished in nursing homes operating in the State.

14 (b) APPLICATIONS AND ELIGIBILITY FOR GRANTS.—

15 (1) INITIAL APPLICATION.—A State seeking a

16 grant to conduct a project under this section shall

17 submit an application containing such information

18 and assurances as the Secretary may require,

19 including—

20 (A) a commitment to submit annual re21 ports describing the State’s progress in increas22 ing staffing levels and making other quality im23 provements in nursing homes in the State; and

24 (B) a description of a plan for evaluation

25 of the activities carried out under the grant, in-
3

HR 5243 IH

1 cluding a plan for measurement of progress to2 ward the goals and objectives of the program,

3 consistent with the principles of the Govern4 ment Performance and Results Act.

5 (2) CONSULTATION WITH PUBLIC.—Before sub6 mitting an application for a grant under this section,

7 States shall solicit and consider the views of mem8 bers of the public, nursing home residents or their

9 representatives, and other persons concerned with

10 the administration of nursing homes within the

11 State with respect to the design of the proposed

12 State program.

13 (3) ELIGIBILITY.—

14 (A) INITIAL ELIGIBILITY.—A State shall

15 not be eligible for a grant award under this sec16 tion unless it makes assurances satisfactory to

17 the Secretary that the skilled nursing facilities

18 (as defined in section 1819(a)) and nursing fa19 cilities (as defined in section 1919(a)) within

20 the State will reach or exceed the minimum

21 staff level described in subsection (d)(2) within

22 two years after enactment of this Act and will

23 maintain such level throughout the remainder

24 of the grant program.
4

HR 5243 IH

1 (B) CONTINUING ELIGIBILITY.—A State

2 shall not be eligible for the continuation of

3 grant funding under a multi-year grant under

4 this section unless the State demonstrates to

5 the Secretary’s satisfaction that it continues to

6 meet the requirement described in subpara7 graph (A) and has made sufficient progress in

8 meeting the goals described in its grant applica9 tion.

10 (c) USE OF GRANT FUNDS.—Funds received by a

11 State under this section may be provided to entities in12 cluding nursing homes, labor management partnerships,

13 and educational institutions, and may be used for any or

14 all of the following purposes:

15 (1) To enable a nursing home to recruit addi16 tional nursing staff or to retain existing nursing

17 staff (including through the use of reasonable finan18 cial incentives or reasonable benefit enhancements).

19 (2) To increase education and training of nurs20 ing staff (including designing or implementing pro21 grams to promote the career advancement of cer22 tified nurse aides).

23 (3) To provide bonuses to nursing homes meet24 ing State quality standards or avoiding serious qual25 ity violations for a period of one or more years.
5

HR 5243 IH

1 (4) Such other nursing home staffing and qual2 ity improvement initiatives as the Secretary may ap3 prove.

4 (d) DISTRIBUTION OF FUNDS.—

5 (1) IN GENERAL.—Subject to subsection (b), in

6 awarding grants under this section, the Secretary

7 shall award no more than 25 percent of the funds

8 to States in which, as of the date of the enactment

9 of this section, skilled nursing facilities (as defined

10 in section 1819(a)) and nursing facilities (as defined

11 in section 1919(a)) have reached or exceeded the

12 minimum staff level specified in paragraph (2) (as

13 determined by the Secretary).

14 (2) MINIMUM NURSING HOME STAFF LEVEL.—

15 (A) IN GENERAL.—Subject to subpara16 graph (B), for purposes of subsection (b) and

17 paragraph (1), the level specified in this para18 graph for a skilled nursing facility or nursing

19 facility is a staff level sufficient to ensure that

20 each resident receives from a certified nurse

21 aide at least 2 hours per day of direct care (in22 cluding repositioning the resident and changing

23 wet clothes, assisting with feeding, exercise, and

24 toileting, and working to enhance a resident’s
6

HR 5243 IH

1 independence with respect to activities of daily

2 living).

3 (B) SECRETARY’S AUTHORITY TO IN4 CREASE MINIMUM STAFF LEVEL.—The Sec5 retary may establish a minimum staff level that

6 is higher than that specified in subparagraph

7 (A). Any such revised staff level shall be effec8 tive no earlier than six months after the date on

9 which Secretary provides notice to States of the

10 new requirement.

11 (3) MULTI-YEAR GRANT FUNDS.—The Sec12 retary shall award any multi-year grant under this

13 section from amounts appropriated (or available pur14 suant to subsection (e)(2)) for the first fiscal year

15 of the grant.

16 (e) APPROPRIATIONS AND AVAILABILITY OF CIVIL

17 MONEY PENALTY (CPM) COLLECTIONS.—

18 (1) APPROPRIATIONS.—There are appropriated

19 for all costs to the Secretary for carrying out the

20 program under this section $200,000,000 for each of

21 fiscal years 2001 through 2005, such funds to re22 main available to the Secretary through the end of

23 the first succeeding fiscal year.

24 (2) AVAILABILITY OF CMP COLLECTIONS.—In

25 addition to the amounts appropriated pursuant to
7

HR 5243 IH

1 paragraph (1), there shall be available to the Sec2 retary for such costs for such fiscal years any

3 amounts deposited in the Nursing Facility Civil

4 Money Penalties Collection Account established

5 under section 4.

6 SEC. 3. ENHANCED NURSING FACILITY REPORTING RE7 QUIREMENTS.

8 (a) MEDICARE.—

9 (1) SUBMISSION OF NURSING STAFF LEVEL

10 DATA TO THE SECRETARY.—Section 1819(b) (42

11 U.S.C. 1395i–3(b)) is amended by adding at the end

12 the following new paragraph:

13 ‘‘(8) DATA ON STAFFING LEVELS.—

14 ‘‘(A) SUBMISSION TO SECRETARY.—A

15 skilled nursing facility shall submit to the Sec16 retary, in such form and manner and at such

17 intervals as the Secretary may require, data

18 with respect to nursing staff of the facility.

19 Such data shall include the total number of

20 nursing staff hours furnished during the period

21 specified by the Secretary (including totals for

22 each shift worked during such period) by the

23 facility to residents for which payment is made

24 under section 1888(e), broken down by total

25 certified nurse aide hours, total licensed prac-
8

HR 5243 IH

1 tical or vocational nurse hours, and total reg2 istered nurse hours, and shall also include the

3 average wage rate for each class of nursing

4 staff employed by the facility.

5 ‘‘(B) PUBLICATION.—The Secretary shall

6 provide for the publication on the Internet Site

7 of the Department of Health and Human Serv8 ices known as Nursing Home Compare the fa9 cility-specific nursing staff information collected

10 pursuant to subparagraph (A). The Secretary

11 shall update such information periodically.’’.

12 (2) POSTING OF INFORMATION ON NURSING FA13 CILITY STAFFING.—Section 1819(b) (42 U.S.C.

14 1395i–3(b)), as amended by paragraph (1), is fur15 ther amended by adding at the end the following

16 new paragraph:

17 ‘‘(9) INFORMATION ON NURSE STAFFING.—

18 ‘‘(A) IN GENERAL.—A skilled nursing fa19 cility shall post daily for each nursing unit of

20 the facility and for each shift the current num21 ber of licensed and unlicensed nursing staff di22 rectly responsible for resident care. The infor23 mation shall be displayed in a uniform manner

24 (as specified by the Secretary) and in a clearly

25 visible place.
9

HR 5243 IH

1 ‘‘(B) PUBLICATION OF DATA.—A skilled

2 nursing facility shall, upon request, make avail3 able to the public the nursing staff data de4 scribed in subparagraph (A).’’.

5 (3) INFORMATION CONCERNING PATIENT CLAS6 SIFICATION.—Section 1819(b)(4)(C) (42 U.S.C.

7 1395i–3(b)(4)(C)) is amended by adding at the end

8 the following new clause:

9 ‘‘(iii) INFORMATION CONCERNING

10 RESIDENTS.—The skilled nursing facility

11 shall provide the Secretary, in such form

12 and manner and at such intervals as the

13 Secretary may require, a classification of

14 all residents of the skilled nursing facility

15 that accords with the patient classification

16 system described in section

17 1888(e)(3)(B)(ii), or such successor system

18 as the Secretary may identify.’’.

19 (b) MEDICAID.—

20 (1) IN GENERAL.—Section 1919(b) (42 U.S.C.

21 1396r) is amended by adding at the end the fol22 lowing new paragraph:

23 ‘‘(8) DATA ON STAFFING LEVELS.—

24 ‘‘(A) SUBMISSION TO SECRETARY.—A

25 nursing facility shall submit to the Secretary, in
10

HR 5243 IH

1 such form and manner and at such intervals as

2 the Secretary may require, data with respect to

3 nursing staff of the facility. Such data shall in4 clude the total number of nursing staff hours

5 furnished during the period specified by the

6 Secretary (including totals for each shift

7 worked during such period) by the facility to

8 residents for which payment is made under this

9 title, broken down by total certified nurse aide

10 hours, total licensed practical or vocational

11 nurse hours, and total registered nurse hours,

12 and shall also include the average wage rate for

13 each class of nursing staff employed by the fa14 cility.

15 ‘‘(B) PUBLICATION.—The Secretary shall

16 provide for the publication on the Internet Site

17 of the Department of Health and Human Serv18 ices known as Nursing Home Compare the fa19 cility-specific nursing staff information collected

20 pursuant to subparagraph (A). The Secretary

21 shall update such information periodically.’’.

22 (2) POSTING OF INFORMATION ON NURSING FA23 CILITY STAFFING.—Section 1919(b) (42 U.S.C.

24 1395r(b)), as amended by paragraph (1), is further
11

HR 5243 IH

1 amended by adding at the end the following new

2 paragraph:

3 ‘‘(9) INFORMATION ON NURSE STAFFING.—

4 ‘‘(A) IN GENERAL.—A nursing facility

5 shall post daily for each nursing unit of the fa6 cility and for each shift the current number of

7 licensed and unlicensed nursing staff directly

8 responsible for resident care. The information

9 shall be displayed in a uniform manner (as

10 specified by the Secretary) and in a clearly visi11 ble place.

12 ‘‘(B) PUBLICATION OF DATA.—A nursing

13 facility shall, upon request, make available to

14 the public the nursing staff data described in

15 subparagraph (A).’’.

16 (3) INFORMATION CONCERNING PATIENT CLAS17 SIFICATION.—Section 1919(b)(4)(C) (42 U.S.C.

18 1396r(b)(4)(C)) is amended by adding at the end

19 the following new clause:

20 ‘‘(iv) INFORMATION CONCERNING

21 RESIDENTS.—The nursing facility shall

22 provide the Secretary, in such form and

23 manner and at such intervals as the Sec24 retary may require, a classification of all

25 residents of the nursing facility that ac-
12

HR 5243 IH

1 cords with the patient classification system

2 described in section 1888(e)(3)(B)(ii), or

3 such successor system as the Secretary

4 may identify.’’.

5 SEC. 4. NURSING FACILITY CIVIL MONEY PENALTY COL6 LECTIONS.

7 (a) ESTABLISHMENT OF NURSING FACILITY CIVIL

8 MONEY PENALTY COLLECTIONS ACCOUNT.—Section

9 1128A (42 U.S.C. 1320a–7a) is amended by adding at

10 the end the following new subsection:

11 ‘‘(o) ESTABLISHMENT OF NURSING FACILITY CIVIL

12 MONEY PENALTY COLLECTIONS ACCOUNT.—There is

13 hereby established an account to be known as the ‘‘Nurs14 ing Facility Civil Money Penalties Collection Account’’

15 (hereafter in this subsection referred to as the ‘‘Ac16 count’’). Notwithstanding any other provision of law, there

17 shall be deposited into the Account the Secretary’s share

18 of any civil monetary penalties collected under sections

19 1819 and 1919, all such amounts to be available without

20 fiscal year limitation for repaying the Secretary’s share

21 of amounts owed to nursing facilities or skilled nursing

22 facilities pursuant to the final sentence of sections

23 1819(h)(2)(B)(ii) and 1919(h)(2)(B)(ii), and for award24 ing grants under section 2 of the Nursing Home Staffing

25 and Quality Improvement Act of 2000.’’.
13

HR 5243 IH

1 (b) AUTHORITY TO COLLECT CMPS IMME2 DIATELY.—

3 (1) MEDICARE.—Section 1819(h)(2)(B)(ii) (42

4 U.S.C. 1395i–3(h)(2)(B)(ii)) is amended by insert5 ing before the final period ‘‘, except that, notwith6 standing section 1128A(c)(2) or any other provision

7 of law, the Secretary, upon determining that a civil

8 money penalty should be imposed against a skilled

9 nursing facility pursuant to this paragraph, shall

10 take immediate action to collect such penalty (except

11 where the Secretary finds that such action could

12 jeopardize the health or welfare of residents of the

13 skilled nursing facility). In collecting such penalty,

14 the Secretary may deduct the amount of the penalty

15 from amounts otherwise payable to the facility under

16 this title or take such other actions as the Secretary

17 considers appropriate. If the Secretary’s imposition

18 of a penalty under this paragraph is set aside, in

19 whole or in part, as a result of a hearing under sec20 tion 1128A(c)(2) (or an appeal therefrom) or by a

21 court of competent jurisdiction, and the Secretary

22 elects not to pursue an appeal of such judgment; or

23 has exhausted all appeals, the Secretary shall repay

24 any amount owed to the skilled nursing facility with

25 accrued interest.’’
14

HR 5243 IH

1 (2) MEDICAID.—Section 1919(h)(3)(B)(ii) (42

2 U.S.C. 1396r(h)(3)(B)(ii)) is amended by inserting

3 before the final period ‘‘, except that, notwith4 standing section 1128A(c)(2) or any other provision

5 of law, the Secretary, upon determining that a civil

6 money penalty should be imposed against a nursing

7 facility pursuant to this paragraph, shall take imme8 diate action to collect the penalty (except where the

9 Secretary finds that such action could jeopardize the

10 health or welfare of residents of the nursing facility).

11 In collecting such penalty, the Secretary may direct

12 the State to deduct the amount of the penalty from

13 amounts otherwise payable to the nursing facility

14 under this title or take such other actions as the

15 Secretary, in consultation with the State, considers

16 appropriate. If the Secretary’s imposition of a pen17 alty under this paragraph is set aside, in whole or

18 in part, as a result of a hearing under section

19 1128A(c)(2) (or an appeal therefrom) or by a court

20 of competent jurisdiction, and the Secretary elects

21 not to pursue an appeal of such judgment, or has

22 exhausted all appeals, the Secretary shall repay, or

23 shall direct the State to repay, any amount owed to

24 the nursing facility with accrued interest.’’

Æ