I

106TH CONGRESS

2D SESSION H. R. 5166

To amend titles XVIII and XIX of the Social Security Act to impose requirements with respect to staffing in nursing facilities receiving Medicare

or Medicaid funding.

IN THE HOUSE OF REPRESENTATIVES

SEPTEMBER 13, 2000

Ms. SCHAKOWSKY (for herself, Mr. RUSH, Mr. BLAGOJEVICH, Mrs. MCCARTHY of New York, Mr. WAXMAN, and Mr. FROST) introduced the following bill; which was referred to the Committee on Ways and Means,

and in addition to the Committee on Commerce, 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 impose requirements with respect to staffing in nursing facilities receiving Medicare or Medicaid funding.

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.

4 This Act may be cited as the ‘‘Quality Care for Nurs5 ing Home Patients Act of 2000’’.
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1 SEC. 2. STAFFING REQUIREMENTS FOR MEDICARE- AND

2 MEDICAID-FUNDED NURSING FACILITIES.

3 (a) MEDICARE-FUNDED SKILLED NURSING FACILI4 TIES.—

5 (1) MINIMUM STANDARDS.—Section 1819(b)(4)

6 of the Social Security Act (42 U.S.C. 1395i–3(b)(4))

7 is amended by adding at the end the following new

8 subparagraph:

9 ‘‘(D) MINIMUM DIRECT CARE STAFFING

10 REQUIREMENTS.—

11 ‘‘(i) LICENSED NURSES.—Subject to

12 subsection (f)(8), a skilled nursing facility

13 must have at least one licensed nurse on

14 duty on the premises for every—

15 ‘‘(I) 15 residents present during

16 the day;

17 ‘‘(II) 20 residents present during

18 the evening; and

19 ‘‘(III) 30 residents present dur20 ing the night.

21 ‘‘(ii) DIRECT CAREGIVERS.—Subject

22 to subsection (f)(8), a skilled nursing facil23 ity must have at least one direct caregiver

24 on duty on the premises for every—

25 ‘‘(I) 5 residents present during

26 the day;
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1 ‘‘(II) 10 residents present during

2 the evening; and

3 ‘‘(III) 15 residents present dur4 ing the night.

5 ‘‘(iii) COUNTING.—In determining

6 compliance with the staffing levels under

7 this subparagraph:

8 ‘‘(I) ADMINISTRATIVE SERV9 ICES.—In a facility with 60 or more

10 beds, an individual may not be count11 ed while performing noncaregiving ad12 ministrative services.

13 ‘‘(II) OTHER SERVICES.—An in14 dividual may not be counted while

15 performing food preparation, house16 keeping, laundry, maintenance serv17 ices, or other noncaregiving-related

18 activities.

19 ‘‘(iv) CONSTRUCTION.—The staffing

20 requirements of this subparagraph are in

21 addition to the requirements of subpara22 graph (C).

23 ‘‘(v) DEFINITIONS.—In this subpara24 graph:
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1 ‘‘(I) LICENSED NURSE.—The

2 term ‘licensed nurse’ means a reg3 istered professional nurse, licensed

4 practical nurse, or licensed vocational

5 nurse who meets State licensing re6 quirements and who provides direct

7 care (including treatment and medica8 tions), who performs resident assess9 ment and observation, who supervises

10 direct patient care at the unit level, or

11 who provides planning or coordination

12 with other resident services.

13 ‘‘(II) DIRECT CAREGIVER.—The

14 term ‘direct caregiver’ means a cer15 tified nurse assistant who provides di16 rect care or a licensed nurse who pro17 vides direct care.

18 ‘‘(III) DAY.—The term ‘day’

19 means an eight-hour period com20 mencing not earlier than 6 a.m. nor

21 later than 8 a.m.

22 ‘‘(IV) EVENING.—The term

23 ‘evening’ means an eight-hour period

24 commencing not earlier than 2 p.m.

25 nor later than 4 p.m.
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1 ‘‘(V) NIGHT.—The term ‘night’

2 means an eight-hour period com3 mencing not earlier than 10 p.m. nor

4 later than 12 midnight.’’.

5 (2) HIGHER STANDARDS.—Section 1819(f) of

6 such Act (42 U.S.C. 1395i–3(f)) is amended by add7 ing at the end the following new paragraph:

8 ‘‘(8) HIGHER STAFFING STANDARDS FOR RESI9 DENTS WITH HIGHER NURSING CARE NEEDS.—

10 ‘‘(A) IN GENERAL.—The Secretary may es11 tablish higher minimum staffing requirements

12 than those under subsection (b)(4)(D), includ13 ing for facilities with a higher percentage of

14 residents with extensive care needs.

15 ‘‘(B) CONSTRUCTION.—Nothing in this

16 paragraph shall be construed to prohibit a

17 State from imposing higher minimum staffing

18 requirements than those under subsection

19 (b)(4)(D) or subparagraph (A).’’.

20 (3) PAYMENT MODIFICATION.—Section

21 1888(e)(4)(G) of such Act is amended by adding at

22 the end the following new clause:

23 ‘‘(iv) ADJUSTMENT TO REFLECT

24 COSTS OF MINIMUM STAFFING.—The Sec25 retary shall provide for an appropriate ad-
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1 justment to account for the costs attrib2 utable to meeting the minimum staffing re3 quirements of subsections (b)(4)(D) and

4 (f)(8) of section 1819.’’.

5 (b) MEDICAID-FUNDED NURSING FACILITIES.—

6 (1) MINIMUM STANDARDS.—Section 1919(b)(4)

7 of such Act (42 U.S.C. 1396r(b)(4)) is amended by

8 adding at the end the following new subparagraph:

9 ‘‘(D) MINIMUM DIRECT CARE STAFFING

10 REQUIREMENTS.—

11 ‘‘(i) LICENSED NURSES.—Subject to

12 subsection (f)(8), a nursing facility must

13 have at least one licensed nurse on duty on

14 the premises for every—

15 ‘‘(I) 15 residents present during

16 the day;

17 ‘‘(II) 20 residents present during

18 the evening; and

19 ‘‘(III) 30 residents present dur20 ing the night.

21 ‘‘(ii) DIRECT CAREGIVERS.—Subject

22 to subsection (f)(8), a nursing facility must

23 have at least one direct caregiver on duty

24 on the premises for every—
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1 ‘‘(I) 5 residents present during

2 the day;

3 ‘‘(II) 10 residents present during

4 the evening; and

5 ‘‘(III) 15 residents present dur6 ing the night.

7 ‘‘(iii) COUNTING.—In determining

8 compliance with the staffing levels under

9 this subparagraph:

10 ‘‘(I) ADMINISTRATIVE SERV11 ICES.—In a facility with 60 or more

12 beds, an individual may not be count13 ed while performing noncaregiving ad14 ministrative services.

15 ‘‘(II) OTHER SERVICES.—An in16 dividual may not be counted while

17 performing food preparation, house18 keeping, laundry, maintenance serv19 ices, or other noncaregiving-related

20 activities.

21 ‘‘(iv) CONSTRUCTION.—The staffing

22 requirements of this subparagraph are in

23 addition to the requirements of subpara24 graph (C).
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1 ‘‘(v) DEFINITIONS.—In this subpara2 graph:

3 ‘‘(I) LICENSED NURSE.—The

4 term ‘licensed nurse’ means a reg5 istered professional nurse, licensed

6 practical nurse, or licensed vocational

7 nurse who meets State licensing re8 quirements and who provides direct

9 care (including treatment and medica10 tions), who performs resident assess11 ment and observation, who supervises

12 direct patient care at the unit level, or

13 who provides planning or coordination

14 with other resident services.

15 ‘‘(II) DIRECT CAREGIVER.—The

16 term ‘direct caregiver’ means a cer17 tified nurse assistant who provides di18 rect care or a licensed nurse who pro19 vides direct care.

20 ‘‘(III) DAY.—The term ‘day’

21 means an eight-hour period com22 mencing not earlier than 6 a.m. nor

23 later than 8 a.m.

24 ‘‘(IV) EVENING.—The term

25 ‘evening’ means an eight-hour period
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1 commencing not earlier than 2 p.m.

2 nor later than 4 p.m.

3 ‘‘(V) NIGHT.—The term ‘night’

4 means an eight-hour period com5 mencing not earlier than 10 p.m. nor

6 later than 12 midnight.’’.

7 (2) HIGHER STANDARDS.—Section 1919(f) of

8 such Act (42 U.S.C. 1396r(f)) is amended by adding

9 at the end the following new paragraph:

10 ‘‘(8) HIGHER STAFFING STANDARDS FOR RESI11 DENTS WITH HIGHER NURSING CARE NEEDS.—

12 ‘‘(A) IN GENERAL.—The Secretary may es13 tablish higher minimum staffing requirements

14 than those under subsection (b)(4)(D), includ15 ing for facilities with a higher percentage of

16 residents with extensive care needs.

17 ‘‘(B) CONSTRUCTION.—Nothing in this

18 paragraph shall be construed to prohibit a

19 State from imposing higher minimum staffing

20 requirements than those under subsection

21 (b)(4)(D) or subparagraph (A).’’.

22 (3) PAYMENT MODIFICATION.—Section

23 1902(a)(13)(A) of such Act is amended—

24 (A) in clause (iii), by striking the final

25 ‘‘and’’;
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1 (B) in clause (iv), by striking the semi2 colon and inserting ‘‘, and’’; and

3 (C) by inserting after clause (iv) the fol4 lowing new clause:

5 ‘‘(v) in the case of nursing facilities,

6 such rates take into account the costs at7 tributable to the requirements of section

8 1919(b)(4)(D).’’.

9 (c) EFFECTIVE DATE.—The amendments made by

10 this section shall apply to services provided on or after

11 the date that is two years after the date of enactment of

12 this Act.

13 (d) REPORT TO CONGRESS ON ADEQUACY OF PER14 SONNEL TO MEET STAFFING REQUIREMENTS.—Not later

15 than one year after the date of enactment of this Act, the

16 Secretary of Health and Human Services shall submit to

17 the Congress a report regarding the adequacy of personnel

18 in nursing facilities covered under titles XVIII and XIX

19 of the Social Security Act to meet the direct care staffing

20 requirements required under the amendments made by

21 this Act to sections 1819(b)(4)(D) and 1919(b)(4)(D) of

22 the Social Security Act (42 U.S.C. 1395i–3(b)(4)(D) and

23 1396r(b)(4)(D)) and, if inadequate, recommendations on

24 steps that should be taken to ensure that adequate num25 bers of trained staff are available to meet such require-
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1 ments, including ways to attract and retain such direct

2 caregiving personnel.

3 SEC. 3. DISCLOSURE OF STAFFING LEVELS AT MEDICARE4 AND MEDICAID-FUNDED NURSING FACILI5 TIES.

6 (a) MEDICARE-FUNDED SKILLED NURSING FACILI7 TIES.—

8 (1) IN GENERAL.—Section 1819(b)(4) of the

9 Social Security Act (42 U.S.C. 1395i–3(b)(4)), as

10 amended by section 2(a)(1) of this Act, is further

11 amended by adding at the end the following new

12 subparagraph:

13 ‘‘(E) DISCLOSURE OF STAFFING LEV14 ELS.—A skilled nursing facility must conspicu15 ously post the following notices adjacent to each

16 other in each area or unit to which such notices

17 apply in the facility in a manner visible and ac18 cessible to residents, their families, caregivers,

19 and prospective residents of such facility and in

20 such a uniform format as the Secretary may

21 prescribe and must retain the information on

22 such notices for at least one year after posting

23 and make such information available upon re24 quest:
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1 ‘‘(i) MINIMUM STAFFING REQUIRE2 MENTS.—A notice describing the minimum

3 staffing requirements set forth in subpara4 graph (D) and, if applicable, subsection

5 (f)(8).

6 ‘‘(ii) CURRENT STAFF INFORMA7 TION.—A notice showing, separately for

8 each shift in the area or unit of the facility

9 in which it is posted—

10 ‘‘(I) the current number of direct

11 caregivers (including licensed nurses)

12 present on the premises who perform

13 resident care and the name and pro14 fessional title of each such caregiver;

15 ‘‘(II) the current ratio of resi16 dents to licensed nurses present on

17 the premises;

18 ‘‘(III) the current ratio of resi19 dents to direct caregivers (including

20 licensed nurses) present on the prem21 ises; and

22 ‘‘(IV) the current number of resi23 dents of such area or unit.’’.

24 (2) CONFORMING AMENDMENT.—Section

25 1819(b)(4)(D)(v) of such Act (42 U.S.C. 1395i–
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1 3(b)(4)(D)(v)), as added by section 2(a)(1) of this

2 Act, is amended by inserting ‘‘and subparagraph

3 (E)’’ after ‘‘this subparagraph’’.

4 (b) MEDICAID-FUNDED NURSING FACILITIES.—

5 (1) IN GENERAL.—Section 1919(b)(4) of such

6 Act (42 U.S.C. 1396r(b)(4)), as amended by section

7 2(b)(1) of this Act, is further amended by adding at

8 the end the following new subparagraph:

9 ‘‘(E) DISCLOSURE OF STAFFING LEV10 ELS.—A nursing facility must conspicuously

11 post the following notices adjacent to each other

12 in each area or unit to which such notices apply

13 in the facility in a manner visible and accessible

14 to residents, their families, caregivers, and pro15 spective residents of such facility and in such a

16 uniform format as the Secretary may prescribe

17 and must retain the information on such no18 tices for at least one year after posting and

19 make such information available upon request:

20 ‘‘(i) MINIMUM STAFFING REQUIRE21 MENTS.—A notice describing the minimum

22 staffing requirements set forth in subpara23 graph (D) and, if applicable, subsection

24 (f)(8).
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1 ‘‘(ii) CURRENT STAFF INFORMA2 TION.—A notice showing, separately for

3 each shift in the area or unit of the facility

4 in which it is posted—

5 ‘‘(I) the current number of direct

6 caregivers (including licensed nurses)

7 present on the premises who perform

8 resident care and the name and pro9 fessional title of each such caregiver;

10 ‘‘(II) the current ratio of resi11 dents to licensed nurses present on

12 the premises;

13 ‘‘(III) the current ratio of resi14 dents to direct caregivers (including

15 licensed nurses) present on the prem16 ises; and

17 ‘‘(IV) the current number of resi18 dents of such area or unit.’’.

19 (2) CONFORMING AMENDMENT.—Section

20 1919(b)(4)(D)(v) of such Act (42 U.S.C.

21 1396r(b)(4)(D)(v)), as added by section 2(b)(1) of

22 this Act, is amended by inserting ‘‘and subpara23 graph (E)’’ after ‘‘this subparagraph’’.

24 (c) EFFECTIVE DATE.—The amendments made by

25 this section shall apply to services provided on or after
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1 the date that is two years after the date of enactment of

2 this Act.

3 SEC. 4. ADMINISTRATIVE STAFFING REQUIREMENTS FOR

4 MEDICARE- AND MEDICAID-FUNDED NURS5 ING FACILITIES.

6 (a) MEDICARE-FUNDED SKILLED NURSING FACILI7 TIES.—

8 (1) MINIMUM STANDARDS.—

9 (A) IN GENERAL.—Section 1819(d)(1) of

10 the Social Security Act (42 U.S.C. 1395i–

11 3(d)(1)) is amended by adding at the end the

12 following new subparagraph:

13 ‘‘(D) ADMINISTRATIVE STAFFING.—A

14 skilled nursing facility must maintain at least

15 the administrative staff described in the fol16 lowing clauses (i) through (iv):

17 ‘‘(i) DIRECTOR OF NURSING SERV18 ICES.—An individual who serves full time

19 as a director of nursing services and who

20 is a registered professional nurse.

21 ‘‘(ii) ASSISTANT DIRECTOR OF NURS22 ING SERVICES.—An individual who serves

23 full time as an assistant director of nurs24 ing services and who is a registered profes25 sional nurse, except that in a facility with
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1 fewer than 100 beds, such individual may

2 serve part time and may also serve as a di3 rect care clinical nursing supervisor.

4 ‘‘(iii) DIRECTOR OF IN-SERVICE EDU5 CATION.—An individual who serves full

6 time as a director of in-service education,

7 who is a registered professional nurse, and

8 who has, to the extent practicable and ap9 propriate, training in adult education and

10 gerontology, except that in a facility with

11 fewer than 100 beds, such individual may

12 serve part time.

13 ‘‘(iv) DIRECT CARE CLINICAL NURS14 ING SUPERVISOR.—For each shift each

15 day, an individual who serves full time as

16 a direct care clinical nursing supervisor

17 and who is a registered professional nurse,

18 except that in a facility with fewer than

19 100 beds, such an individual may serve

20 part time and may also serve as an assist21 ant director of nursing.

22 ‘‘(v) LIMITATION ON FULFILLMENT

23 OF ADMINISTRATIVE PERSONNEL REQUIRE24 MENTS.—An individual cannot satisfy

25 more than one requirement of clauses (i)
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1 through (iv), except as specifically pro2 vided.’’.

3 (B) CONFORMING AMENDMENT.—Section

4 1819(b)(4)(D)(v) of such Act (42 U.S.C.

5 1395i–3(b)(4)(D)(v)), as added by section

6 2(a)(1) and amended by section 3(a)(2) of this

7 Act, is further amended by striking ‘‘and sub8 paragraph (E)’’ and inserting ‘‘, subparagraph

9 (E), and subsection (d)(1)(D)’’.

10 (2) PAYMENT MODIFICATION.—Section

11 1888(e)(4)(G)(iv) of such Act (42 U.S.C.

12 1395yy(e)(4)(G)(iv)), as added by section 2(a)(3) of

13 this Act, is amended by striking ‘‘section

14 1819(b)(4)(D)’’ and inserting ‘‘subsections

15 (b)(4)(D) and (d)(1)(D) of section 1819’’.

16 (b) MEDICAID-FUNDED NURSING FACILITIES.—

17 (1) MINIMUM STANDARDS.—

18 (A) IN GENERAL.—Section 1919(d)(1) of

19 such Act (42 U.S.C. 1396r(d)(1)) is amended

20 by adding at the end the following new sub21 paragraph:

22 ‘‘(D) ADMINISTRATIVE STAFFING.—A

23 nursing facility must maintain at least the ad24 ministrative staff described in the following

25 clauses (i) through (iv):
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1 ‘‘(i) DIRECTOR OF NURSING SERV2 ICES.—An individual who serves full time

3 as a director of nursing services and who

4 is a registered professional nurse.

5 ‘‘(ii) ASSISTANT DIRECTOR OF NURS6 ING SERVICES.—An individual who serves

7 full time as an assistant director of nurs8 ing services and who is a registered profes9 sional nurse, except that in a facility with

10 fewer than 100 beds, such individual may

11 serve part time and may also serve as a di12 rect care clinical nursing supervisor.

13 ‘‘(iii) DIRECTOR OF IN-SERVICE EDU14 CATION.—An individual who serves full

15 time as a director of in-service education,

16 who is a registered professional nurse, and

17 who has, to the extent practicable and ap18 propriate, training in adult education and

19 gerontology, except that in a facility with

20 fewer than 100 beds, such individual may

21 serve part time.

22 ‘‘(iv) DIRECT CARE CLINICAL NURS23 ING SUPERVISOR.—For each shift each

24 day, an individual who serves full time as

25 a direct care clinical nursing supervisor
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1 and who is a registered professional nurse,

2 except that in a facility with fewer than

3 100 beds, such an individual may serve

4 part time and may also serve as an assist5 ant director of nursing.

6 ‘‘(v) LIMITATION ON FULFILLMENT

7 OF ADMINISTRATIVE PERSONNEL REQUIRE8 MENTS.—An individual cannot satisfy

9 more than one requirement of clauses (i)

10 through (iv), except as specifically pro11 vided.’’.

12 (B) CONFORMING AMENDMENT.—Section

13 1919(b)(4)(D)(v) of such Act (42 U.S.C.

14 1396r(b)(4)(D)(v)), as added by section 2(b)(1)

15 and amended by section 3(b)(2) of this Act, is

16 further amended by striking ‘‘and subparagraph

17 (E)’’ and inserting ‘‘, subparagraph (E), and

18 subsection (d)(1)(D)’’.

19 (2) PAYMENT MODIFICATION.—Section

20 1902(a)(13)(A)(v) of such Act (42 U.S.C.

21 1396a(a)(13)(A)(v)), as added by section 2(b)(3) of

22 this Act, is amended by striking ‘‘section

23 1919(b)(4)(D)’’ and inserting ‘‘subsections

24 (b)(4)(D) and (d)(1)(D) of section 1919’’.
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1 (e) EFFECTIVE DATE.—The amendments made by

2 this section shall apply to services provided on or after

3 the date that is two years after the date of enactment of

4 this Act.

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