II 

112TH CONGRESS 

1ST SESSION S. 2022 

To establish a demonstration program to test the viability of community 

integrated small-house nursing care homes. 

IN THE SENATE OF THE UNITED STATES 

DECEMBER 16, 2011 

Mr. CASEY (for himself, Mr. ENZI, Mr. SCHUMER, and Mr. WICKER) introduced the following bill; which was read twice and referred to the Committee on Finance 

A BILL 

To establish a demonstration program to test the viability 

of community integrated small-house nursing care homes. 

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 ‘‘Community Integrated 

5 Nursing Care Homes Demonstration Program Act’’ or the 

6 ‘‘CINCH Demonstration Program Act’’. 

7 SEC. 2. DEFINITIONS. 

8 In this Act: 


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1 (1) CINCH DEMONSTRATION PROGRAM.—The 

2 term ‘‘CINCH demonstration program’’ means the 

3 demonstration program conducted under this Act. 

4 (2) MEDICAID.—The term ‘‘Medicaid’’ means 

5 the program for medical assistance established under 

6 title XIX of the Social Security Act (42 U.S.C. 1396 

7 et seq.). 

8 (3) MEDICARE.—The term ‘‘Medicare’’ means 

9 the program for medical assistance established under 

10 title XVIII of the Social Security Act (42 U.S.C. 

11 1395 et seq.). 

12 (4) NURSING HOME.—The term ‘‘nursing 

13 home’’ means— 

14 (A) a skilled nursing facility (as defined in 

15 section 1819(a) of the Social Security Act (42 

16 U.S.C. 1395i–3(a))); or 

17 (B) a nursing facility (as defined in section 

18 1919(a) of the Social Security Act (42 U.S.C. 

19 1396r(a))). 

20 (5) RESEARCH-BASED.—The term ‘‘research21 based’’ means research that— 

22 (A) has been conducted by an objective re23 searcher or research team that has— 


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1 (i) no financial or affiliated organiza2 tional interest in the success of the model; 

3 and 

4 (ii) expertise in long-term care, with 

5 not less than 3 research articles relating to 

6 long-term care that have been published in 

7 leading peer-reviewed journals; 

8 (B) has been conducted according to gen9 erally accepted research practices; 

10 (C) has been published in a leading peer11 reviewed journal on aging or long-term care; 

12 and 

13 (D) indicates a measurable improvement in 

14 multiple aspects of quality of life and care. 

15 (6) SECRETARY.—The term ‘‘Secretary’’ means 

16 the Secretary of Health and Human Services. 

17 (7) RURAL AREA.—The term ‘‘rural area’’ 

18 means any area other than an urban or suburban 

19 area. 

20 (8) SUBURBAN AREA.—The term ‘‘suburban 

21 area’’ means any urbanized area that is contiguous 

22 and adjacent to an urban area. 

23 (9) URBAN AREA.—The term ‘‘urban area’’ 

24 means a city or town that has a population of great25 er than 50,000 inhabitants. 


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1 SEC. 3. SMALL-HOUSE NURSING CARE HOME REQUIRE2 MENTS. 

3 To be eligible to participate in the CINCH dem4 onstration program as a small-house nursing care home, 

5 a nursing home shall— 

6 (1) subject to section 4(f), have been certified 

7 by a Federal, State, or local entity (in accordance 

8 with applicable Federal, State, and local law) to op9 erate a nursing home; 

10 (2) operate in compliance with any direct care 

11 and certified nurse assistant staffing requirements 

12 under Federal, State, and local law; 

13 (3) provide nursing home services, as required 

14 under State law and applicable licensing standards, 

15 that shall not be less comprehensive or high-acuity 

16 than services provided by the eligible operating enti17 ty within the immediate surrounding community; 

18 (4) provide for meals cooked in the nursing 

19 home and not prepared in a central kitchen and 

20 transported to the home; 

21 (5) provide for a universal worker approach to 

22 resident care (such as a certified nursing assistant 

23 who provides personal care, socialization services, 

24 meal preparation services, and laundry and house25 keeping services); 


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1 (6) provide for direct care staffing at a rate 

2 that meets applicable Federal and State require3 ments or that is not less than 4 hours per resident 

4 per day, whichever is greater, with direct care staff 

5 (including certified nurse assistants) to be onsite, 

6 awake, and available within each small-house nurs7 ing care home at all times; 

8 (7) provide for direct nursing care at a rate 

9 that meets applicable Federal and State require10 ments or that is not less than 1 hour per resident 

11 per day, whichever is greater, with a nursing staff 

12 that is awake and available at each location at all 

13 times and that meets or exceeds applicable Federal 

14 and State requirements for qualifications, services, 

15 and availability; 

16 (8) provide for any other clinical, operational, 

17 management, or facility staff and services as re18 quired under applicable Federal and State require19 ments, with such staff to be available from central20 ized or distributed locations, including a director of 

21 nursing who shall be responsible for oversight of the 

22 nursing staff within a site; 

23 (9) provide for consistent staff assignments and 

24 self-directed work teams of direct care staff; 


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1 (10) provide training for all staff involved in 

2 the operations of the nursing home (for not less 

3 than 120 hours for each universal worker and not 

4 less than 60 hours for each leadership and clinical 

5 team member, to be completed for the majority of 

6 the staff before they start to work in a small-house 

7 nursing care home) concerning the philosophy, oper8 ations, and skills required to implement and main9 tain self-directed care, self-managed work teams, a 

10 noninstitutional approach to life and care in long11 term care, appropriate safety and emergency skills, 

12 cooking from scratch by the direct care staff and 

13 food handling and safety, and other elements re14 quired for successful operation of the small-house 

15 nursing care home; 

16 (11) ensure that the percentage of residents in 

17 each small-house nursing care home who are short18 stay rehabilitation residents does not exceed 20 per19 cent at any time (unless the small-house nursing 

20 care home is entirely devoted to providing rehabilita21 tion services), except that a long-term resident 

22 transferring back to a small-house nursing care 

23 home after an acute episode and who is receiving re24 habilitation services for which payment is made 


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1 under Medicare shall not be counted toward such 

2 limitation; 

3 (12) provide the technical assistance provider 

4 with Minimum Data Set (‘‘MDS’’) information and 

5 financial data in a timely manner on a monthly 

6 basis; and 

7 (13) consist of a physical environment designed 

8 to look and feel like a home, rather than an institu9 tion, and that shall— 

10 (A) be designed to serve as a fully inde11 pendent, self-sufficient, and disabled accessible 

12 house or apartment that is similar to housing 

13 available within the immediate surrounding 

14 community, with not more than 10 residents 

15 within such house or apartment, and that shall 

16 only be connected to or share areas that would 

17 be generally shared between private homes 

18 (such as a driveway) or apartments (such as a 

19 lobby or laundry room); 

20 (B) contain residential-style design ele21 ments and materials throughout the home that 

22 are similar to those in the immediate sur23 rounding community and that do not use com24 mercial and institutional elements and products 

25 (such as a nurses’ station, medication carts, 


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1 hospital or office-type florescent lighting, acous2 tical tile ceilings, institutional-style railings and 

3 corner guards, and room numbering and label4 ing) unless mandated by authorities with appro5 priate jurisdiction over the nursing home; 

6 (C) provide private, single occupancy bed7 rooms that— 

8 (i) are shared only at the request of 

9 a resident to accommodate a spouse, part10 ner, family member, or friend, and that 

11 contains a full private bathroom that in12 cludes, at a minimum, a toilet, sink, and 

13 accessible shower; and 

14 (ii) are dually certified for occupancy 

15 by a Medicaid or Medicare eligible indi16 vidual; 

17 (D) contain a living area where residents 

18 and staff may socialize, dine, and prepare food 

19 together that provides, at a minimum, a living 

20 room seating area, a dining area large enough 

21 for a single table serving all residents and not 

22 less than 2 staff members, and a full kitchen 

23 that is open to the living and dining areas; 

24 (E) contain ample natural light in each 

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1 rior windows and other means, with window 

2 areas, exclusive of skylights and clerestories, 

3 being a minimum of 10 percent of the area of 

4 the room; 

5 (F) have a life-safety rating that is suffi6 cient to meet State and local standards for 

7 nursing facilities, including such provisions of 

8 such edition (as specified by the Secretary in 

9 regulation) of the Life Safety Code of the Na10 tional Fire Protection Association as are appli11 cable to nursing homes, appropriately accommo12 date individuals who cannot evacuate the small13 house nursing care home without assistance, 

14 and satisfy applicable requirements under the 

15 Americans with Disabilities Act of 1990 (42 

16 U.S.C. 12101 et seq.); and 

17 (G) contain built-in safety features to allow 

18 all areas of the small-house nursing care home 

19 to be accessible to residents during the majority 

20 of the day and night. 

21 SEC. 4. ESTABLISHMENT OF COMMUNITY INTEGRATED 

22 NURSING CARE HOMES DEMONSTRATION 

23 PROGRAM. 

24 (a) IN GENERAL.—The Secretary shall establish the 

25 CINCH demonstration program to test the viability of 


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1 multiple small-house nursing care homes that are embed2 ded within residential neighborhoods and collectively cer3 tified to provide services through a single eligible oper4 ating entity in order to reduce administrative costs and 

5 provide related cost savings to the Medicare and Medicaid 

6 programs. 

7 (b) DURATION AND SCOPE.— 

8 (1) DURATION.—The Secretary shall conduct 

9 the CINCH demonstration program for a period of 

10 5 years. 

11 (2) SCOPE.—The Secretary shall select not 

12 more than 6 sites (as described in subsection (c)(2)) 

13 to participate in the CINCH demonstration pro14 gram, with each site to be operated by a different 

15 eligible operating entity (as described under section 

16 5(b)), with not less than 2 sites to be located in 

17 rural areas. 

18 (c) STRUCTURE OF DEMONSTRATION PROGRAM.— 

19 (1) ELIGIBLE OPERATING ENTITY.— 

20 (A) IN GENERAL.—Each site shall be oper21 ated by a single eligible operating entity under 

22 the entity’s nursing home license and provider 

23 certification, with such entity to be responsible 

24 for management, administration, and oversight 


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1 of all small-house nursing care homes within 

2 the site. 

3 (B) ENTITIES.—For purposes of this Act, 

4 an eligible operating entity shall be— 

5 (i) a skilled nursing facility (as de6 fined in section 1819(a) of the Social Secu7 rity Act (42 U.S.C. 1395i–3(a))); 

8 (ii) a nursing facility (as defined in 

9 section 1919(a) of the Social Security Act 

10 (42 U.S.C. 1396r(a))); or 

11 (iii) an entity that has applied for cer12 tification pursuant to Federal, State, and 

13 local requirements for operation of a 

14 skilled nursing facility or nursing facility, 

15 provided that— 

16 (I) the proposal submitted by the 

17 entity pursuant to section 5(b) in18 cludes a plan for certification that has 

19 been determined by the technical as20 sistance provider to be feasible and 

21 likely to result in certification by the 

22 State; and 

23 (II) the entity receives such cer24 tification not later than 24 months 

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1 ance provider (as described in section 

2 5(b)). 

3 (C) RELATIONSHIP TO NURSING CARE

4 HOMES WITHIN SITE.—A facility that has been 

5 designated as the eligible operating entity— 

6 (i) shall not be considered to be small7 house nursing care home for purposes of 

8 site and location requirements under this 

9 section; and 

10 (ii) shall not be subject to require11 ments for small-house nursing care homes 

12 under section 3. 

13 (2) SITE.— 

14 (A) IN GENERAL.—A site shall consist 

15 of— 

16 (i) not less than 2 locations (as de17 scribed in paragraph (3)); and 

18 (ii) not less than a total of 4 small19 house nursing care homes (as described in 

20 section 3) and not greater than a total 

21 of— 

22 (I) in rural areas (or a site that 

23 encompasses a rural area), 12 small24 house nursing care homes; or 


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1 (II) in urban or suburban areas, 

2 24 small-house nursing care homes. 

3 (B) DISTANCES BETWEEN LOCATIONS

4 WITHIN A SITE.—Distances between locations 

5 within a site may vary based upon market de6 mand and availability, with maximum distances 

7 between locations to be established by the eligi8 ble operating entity based upon the ability of 

9 such entity to— 

10 (i) deliver required services and super11 vision in a timely and appropriate manner; 

12 and 

13 (ii) subject to subsection (f), meet all 

14 applicable statutory and regulatory re15 quirements for operation of a nursing 

16 home. 

17 (3) LOCATION.— 

18 (A) IN GENERAL.—Each location shall 

19 consist of not greater than 2 small-house nurs20 ing care homes. 

21 (B) ADJOINING PARCELS.—A location 

22 shall— 

23 (i) consist of a single parcel of land or 

24 multiple adjoining parcels of land; and 


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1 (ii) be separate from any other loca2 tion and operate on a non-adjoining parcel 

3 of land from such location. 

4 (d) CONTINUATION OF TREATMENT AS SINGLE PRO5 VIDER.—The Secretary shall develop a process to allow a 

6 site, following the 5-year period for the CINCH dem7 onstration program, to continue operation through a sin8 gle operating entity and receive certification as a single 

9 provider for purposes of Medicare and Medicaid, including 

10 provisions to permit such continuation following a change 

11 in ownership of a participating small-house nursing care 

12 home. 

13 (e) PRIORITY FOR CERTIFICATION OF COMPLI14 ANCE.—For purposes of certifying compliance of nursing 

15 homes with Federal participation requirements under 

16 Medicare and Medicaid, the Secretary shall give priority 

17 to the review and certification of any nursing homes par18 ticipating in the CINCH demonstration program. 

19 (f) WAIVER AUTHORITY.—The Secretary may waive 

20 such requirements of titles XI, XVIII, and XIX of the So21 cial Security Act as may be necessary to carry out the 

22 CINCH demonstration program and shall develop a proc23 ess that permits sites to be certified and reimbursed under 

24 Medicare and Medicaid. 


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1 SEC. 5. SELECTION. 

2 (a) TECHNICAL ASSISTANCE PROVIDER.— 

3 (1) IN GENERAL.—Not later than 90 days after 

4 the date of enactment of this Act, the Secretary, 

5 through a request for proposal process, shall select 

6 a technical assistance provider that shall be respon7 sible for— 

8 (A) selecting, assisting, and evaluating the 

9 performance of eligible operating entities (as 

10 described under subsection (b)); and 

11 (B) ensuring that small-house nursing care 

12 homes satisfy the requirements described in sec13 tion 3. 

14 (2) MINIMUM REQUIREMENTS.—In selecting the 

15 technical assistance provider, the Secretary shall en16 sure that such organization— 

17 (A) is a national not-for-profit organization 

18 that is in good standing; 

19 (B) has a consistent, clearly articulated, 

20 and research-based model for operation of 

21 small-house nursing care homes; 

22 (C) has not less than 10 years of experi23 ence in providing development, operation, regu24 latory, policy, and financial consulting services 

25 to clients or partners seeking to innovate the 

26 provision of long-term care; 


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1 (D) has demonstrated a successful process 

2 and record (for not less than 4 years) for selec3 tion and assistance of multiple organizations in 

4 implementation of a small-house nursing care 

5 home model, including development, operations, 

6 and staff training; 

7 (E) has established curricula for training 

8 of leadership, clinical, and direct care staff; 

9 (F) has demonstrated capacity, through its 

10 own resources and consultants, to— 

11 (i) collect MDS information and fi12 nancial data from eligible operating enti13 ties; and 

14 (ii) benchmark and analyze such fi15 nancial data on not less than a quarterly 

16 basis; 

17 (G) has the ability to administer the 

18 CINCH demonstration program without addi19 tional funding from Federal, State, or local gov20 ernmental sources; 

21 (H) agrees to provide technical assistance 

22 services to eligible operating entities for a fee 

23 that is not greater than its usual and cus24 tomary fee for such services; and 


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1 (I) agrees to maintain a provider network 

2 for small-house nursing care homes partici3 pating in the CINCH demonstration program 

4 for a fee that is not greater than its usual and 

5 customary fee for such services. 

6 (3) PREFERENCES.—In selecting the technical 

7 assistance provider, the Secretary shall give pref8 erence to an organization that has demonstrated ex9 perience in related business activities, including com10 munity-based care models, health care financing, 

11 and demonstration programs. 

12 (b) ELIGIBLE OPERATING ENTITY.— 

13 (1) IN GENERAL.—Selection of eligible oper14 ating entities shall be determined by the technical 

15 assistance provider through a request for proposal 

16 process on a continual basis. 

17 (2) MINIMUM REQUIREMENTS.—An eligible op18 erating entity seeking to participate in the CINCH 

19 demonstration program shall be required to— 

20 (A) commit to maintaining the small-house 

21 nursing care home requirements described 

22 under section 3 and permit the technical assist23 ance provider to conduct periodic evaluations to 

24 ensure adherence to such requirements; 


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1 (B) maintain membership in a small-house 

2 nursing care home provider network that is 

3 maintained by the technical assistance provider; 

4 and 

5 (C) subject to paragraph (3)(B), ensure 

6 that not less 30 percent of the total capacity 

7 developed under the CINCH demonstration pro8 gram within the site, based on the annual aver9 age for such site, is provided to residents that 

10 are receiving nursing home benefits under Med11 icaid, with any remaining capacity to be made 

12 available to any individual seeking nursing 

13 home services (including individuals eligible for 

14 Medicare, privately insured individuals, or indi15 viduals paying for their own care). 

16 (3) ADDITIONAL CONSIDERATIONS.—For pur17 poses of selecting eligible operating entities to par18 ticipate in the CINCH demonstration project, the 

19 technical assistance provider shall take into consider20 ation— 

21 (A) the level and extent of services that 

22 will be provided to residents by each small23 house nursing care home within the site, includ24 ing whether such services are sufficient to re25 spond to the changing needs of residents as 


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1 they advance in age and thereby permit them to 

2 continue to reside in the home; and 

3 (B) whether an entity commits to a per4 centage of total capacity within the site to resi5 dents that are receiving nursing home benefits 

6 under Medicaid that is higher than the min7 imum percentage of total capacity described in 

8 paragraph (2)(C). 

9 SEC. 6. NO ADDITIONAL PAYMENT. 

10 The technical assistance provider, as well as any eligi11 ble operating entities and participating small-house nurs12 ing care homes, shall not receive any additional payment 

13 or reimbursement under Medicare or Medicaid based upon 

14 their participation in the CINCH demonstration program. 

15 SEC. 7. EVALUATION AND REPORT. 

16 (a) IN GENERAL.—Not later than 4 years after the 

17 date of enactment of this Act, the technical assistance pro18 vider shall evaluate the performance of each of the sites 

19 participating under the CINCH demonstration program 

20 and shall submit to the Secretary a report containing the 

21 results of such evaluation. 

22 (b) EVALUATION REQUIREMENTS.—The evaluation 

23 described in subsection (a) shall include an analysis of— 


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1 (1) not less than 12 months of MDS informa2 tion and financial data from at least 10 small-house 

3 nursing care homes; and 

4 (2) results from focus groups or surveys regard5 ing health outcomes for residents and program costs. 

6 (c) TESTING AND EXPANSION THROUGH THE CEN7 TER FOR MEDICARE AND MEDICAID INNOVATION.—Not 

8 later than 6 months after receiving the report submitted 

9 under subsection (a), the Secretary shall, through the Cen10 ter for Medicare and Medicaid Innovation established 

11 under section 1115A of the Social Security Act (42 U.S.C. 

12 1315A), perform an evaluation (as described in subsection 

13 (b)(4) of such section) of the CINCH demonstration pro14 gram and, pursuant to the requirements under subsection 

15 (c) of such section, determine whether an expansion of the 

16 CINCH demonstration program is appropriate. 

Æ 


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