II

106TH CONGRESS

2D SESSION S. 3177

To require the Secretary of Health and Human Services to establish minimum

nursing staff levels for nursing facilities, to provide for grants to improve

the quality of care furnished in nursing facilities, and for other purposes.

IN THE SENATE OF THE UNITED STATES

OCTOBER 5 (legislative day, SEPTEMBER 22), 2000

Mr. GRASSLEY (for himself, Mr. BREAUX, and Mr. REED) introduced the

following bill; which was read twice and referred to the Committee on Finance

A BILL

To require the Secretary of Health and Human Services

to establish minimum nursing staff levels for nursing

facilities, to provide for grants to improve the quality

of care furnished in nursing facilities, 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.

4 This Act may be cited as the ‘‘Nursing Home Staff

5 Improvement Act of 2000’’.

6 SEC. 2. FINDINGS.

7 Congress makes the following findings:
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1 (1) Part I of the Health Care Financing Ad2 ministration’s Report to Congress: Appropriateness

3 of Minimum Nurse Staffing Ratios in Nursing

4 Homes was completed in August of 2000 and

5 showed the following:

6 (A) Quality of care may be significantly

7 impaired when staffing thresholds fall below 2.0

8 nurse aide hours per resident day, 1.0 reg9 istered nurse and licensed practical nurse hours

10 per resident day and 0.45 registered nurse

11 hours per resident day.

12 (B) Below this threshold, residents are

13 more likely to suffer life threatening illnesses

14 secondary to pressure sores, weight loss and

15 preventable infections, and rates of avoidable

16 hospitalization increase significantly.

17 (C) Fifty-four percent of nursing home fa18 cilities do not provide 2.0 nurse aide hours per

resident day and approximately 1 19 ⁄2 of nursing

20 home facilities would require greater than a 10

21 percent change in staffing to meet this minimal

22 standard.

23 (D) The 2.0 nurse aide hours per resident

24 day is a threshold below which residents lives
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1 are at risk, not a standard for the provision of

2 appropriate care.

3 (2)(A) A minimum of 2.9 nurse aide hours per

4 resident day are necessary to deliver 5 necessary

5 daily care services.

6 (B) Over 92 percent of nursing home facilities

7 fall below the 2.9 nurse aide hours per resident day

8 standard and would require a 50 percent increase in

9 staffing to meet this standard.

10 (C) The 2.9 nurse aide hours per resident day

11 standard is based on a conservative assumption and

12 understates the real staffing levels necessary for a

13 nurse aide to complete all tasks that constitute ade14 quate care.

15 (3)(A) Facilities that serve residents with more

16 complex medical conditions will require higher staff17 ing levels.

18 (B) Minimum staffing levels that take into ac19 count case mix have not yet been established.

20 (C) Part II of the Health Care Financing Ad21 ministration report, which has not yet been com22 pleted, will report to Congress on minimum staffing

23 levels according to the facility’s resident acuity level.
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1 SEC. 3. COMPLETION OF REPORT TO CONGRESS ON ADE2 QUATE NURSING FACILITY STAFFING RE3 QUIREMENTS.

4 (a) IN GENERAL.—Section 4801(e)(17)(B) of the

5 Omnibus Budget Reconciliation Act of 1990 (42 U.S.C.

6 1396r note) is amended—

7 (1) by striking ‘‘January 1, 1999’’ and insert8 ing ‘‘July 1, 2001’’;

9 (2) by inserting ‘‘and optimal minimum’’ after

10 ‘‘minimum’’ each place it appears;

11 (3) by striking the period and inserting a semi12 colon;

13 (4) by striking ‘‘such study recommendations’’

14 and inserting ‘‘such study—

15 ‘‘(i) recommendations’’; and

16 (5) by adding at the end the following:

17 ‘‘(ii) an examination of the cost and

18 benefits associated with establishing staff19 ing minimum and optimal minimum ratios;

20 ‘‘(iii) a description of the data used in

21 Phase II of the study to expand the multi22 variate analysis from 3 States to a more

23 representative national sample;

24 ‘‘(iv) an analysis of proposed refined

25 case mix classification methods considered

26 in Phase II of the study;
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1 ‘‘(v) a description of the case studies

2 used to validate the Phase I findings of the

3 study; and

4 ‘‘(vi) an examination of other issues

5 that impact the recruitment and retention

6 of certified nursing assistants.’’.

7 (b) EFFECTIVE DATE.—The amendments made by

8 subsection (a) take effect as if included in the enactment

9 of section 4801 of the Omnibus Budget Reconciliation Act

10 of 1990 (Public Law 101–508; 104 Stat. 1388–211).

11 SEC. 4. ESTABLISHMENT OF APPROPRIATE MINIMUM

12 STAFFING REQUIREMENTS.

13 (a) NOTICE OF PROPOSED RULEMAKING.—Not later

14 than 6 months after the date that the Secretary of Health

15 and Human Services (in this section referred to as the

16 ‘‘Secretary’’) submits the report to Congress required

17 under section 4801(e)(17)(B) of the Omnibus Budget

18 Reconciliation Act of 1990 (42 U.S.C. 1396r note) regard19 ing the study of establishing appropriate minimum care20 giver to resident levels and appropriate minimum super21 visor to caregiver levels for skilled nursing facilities par22 ticipating as providers of services under the medicare pro23 gram under title XVIII of the Social Security Act (42

24 U.S.C. 1395 et seq.) and nursing facilities receiving pay25 ments under the medicaid program under title XIX of
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1 such Act (42 U.S.C. 1396 et seq.) that includes rec2 ommendations regarding appropriate minimums for such

3 levels, the Secretary shall issue a notice of proposed rule4 making with respect to the promulgation of a final regula5 tion requiring compliance with appropriate minimum care6 giver to resident levels and appropriate minimum super7 visor to caregiver levels as a condition for such facilities

8 to receive payments under such programs.

9 (b) FINAL REGULATION.—Not later than 6 months

10 after the issuance of the notice required under subsection

11 (a), the Secretary shall issue the final regulation (to be

12 effective upon publication) that was the subject of such

13 notice.

14 (c) DEFINITION OF APPROPRIATE.—In this section,

15 the term ‘‘appropriate’’ means the staffing threshold level

16 required to attain a good or optimal quality outcome with

17 respect to a resident of a skilled nursing facility partici18 pating as a provider of services under the medicare pro19 gram under title XVIII of the Social Security Act (42

20 U.S.C. 1395 et seq.) or of a nursing facility receiving pay21 ments under the medicaid program under title XIX of

22 such Act (42 U.S.C. 1396 et seq.), as opposed to avoiding

23 a bad outcome with respect to such a resident.
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1 SEC. 5. GRANTS TO IMPROVE STAFFING LEVELS AND THE

2 QUALITY OF CARE IN NURSING FACILITIES.

3 (a) AUTHORITY TO AWARD GRANTS.—The Secretary

4 of Health and Human Services shall award grants to

5 States on a competitive basis for the purpose of improving

6 staffing levels in nursing facilities in order to improve the

7 quality of care to residents of such facilities.

8 (b) APPLICATIONS.—Each State that wishes to re9 ceive a grant under this section shall submit an application

10 at such time, in such form, and complete with such infor11 mation as the Secretary may require, except that any such

12 application shall include at least a certification that the

13 application was developed through an open, public process.

14 (c) REQUIREMENTS FOR USE OF FUNDS.—

15 (1) PERMISSIBLE USES.—

16 (A) IN GENERAL.—A State awarded a

17 grant under this section shall use funds pro18 vided under the grant to provide financial sup19 port or technical assistance for projects oper20 ated by nursing facilities, labor organizations,

21 nonprofit organizations, community colleges, or

22 other organizations, or through joint efforts of

23 such entities and organizations, that are de24 signed to do any or all of the following:

25 (i) Enhance staff recruitment and re26 tention efforts.
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1 (ii) Establish centers of expertise and

2 training.

3 (iii) Establish career ladders for cer4 tified nurse assistants, including additional

5 or advanced training opportunities.

6 (iv) Provide additional training for

7 nursing facility direct care staff.

8 (v) Improve workplace safety.

9 (vi) Improve nursing facility manage10 ment.

11 (vii) Conduct other staffing initiatives

12 to improve patient outcomes, as approved

13 by the Secretary.

14 (B) APPLICABILITY OF NURSING HOME RE15 FORM PROVISIONS.—Funds made available

16 under a grant awarded to a State under this

17 section may only be used to provide financial

18 support or technical assistance for any project

19 described in subparagraph (A) to the extent

20 that the activities conducted under the project

21 are consistent with the requirements of sections

22 1818 and 1919 of the Social Security Act (42

23 U.S.C. 1395i–3, 1396r).

24 (C) PROHIBITION.—No funds made avail25 able under a grant awarded to a State under
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1 this section may be used to provide financial

2 support or technical assistance for any project

3 described in subparagraph (A) that is con4 ducted at, or for the benefit of, a nursing facil5 ity that is owned or operated by a State, coun6 ty, or local government.

7 (2) NO SUPPLANTATION OF FUNDS.—Funds

8 made available under a grant awarded to a State

9 under this section may only be used to supplement,

10 not supplant, other funds that the State expends to

11 carry out activities described in paragraph (1)(A).

12 (d) AUTHORIZATION OF APPROPRIATIONS.—There

13 are authorized to be appropriated to the Secretary for pur14 poses of carrying out this section $500,000,000 for each

15 of fiscal years 2001 and 2002. Funds appropriated in ac16 cordance with this subsection for a fiscal year shall remain

17 available through the end of the succeeding fiscal year.

18 (e) REPORTS AND SECRETARIAL EVALUATION.—

19 (1) STATE FINAL REPORTS.—Each State that

20 is awarded a grant under this section shall submit

21 a final report to the Secretary on the use of funds

22 awarded under the grant not later than 3 months

23 after the earlier of—

24 (A) the completion of the project or

25 projects provided financial support or technical
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1 assistance with funds received under the grant;

2 or

3 (B) the conclusion of the 2-year period

4 that begins on the date that the State receives

5 such grant funds.

6 (2) SECRETARIAL EVALUATION AND REPORT.—

7 Not later than 6 months after the final State report

8 is submitted to the Secretary under paragraph (1),

9 the Secretary shall submit to Congress a report eval10 uating the extent to which the grant program estab11 lished under this section assists States in improving

12 staffing levels in nursing facilities.

13 (f) DEFINITIONS.—In this section:

14 (1) NURSING FACILITY.—The term ‘‘nursing

15 facility’’ means a skilled nursing facility partici16 pating in the medicare program established under

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

18 1395 et seq.) or a nursing facility receiving pay19 ments under the medicaid program established

20 under title XIX of such Act (42 U.S.C. 1396 et

21 seq.).

22 (2) SECRETARY.—The term ‘‘Secretary’’ means

23 the Secretary of Health and Human Services.
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1 SEC. 6. PROVIDING ACCURATE INFORMATION ON STAFF2 ING.

3 (a) MEDICARE.—

4 (1) DATA ON STAFFING LEVELS.—Section

5 1819(b) of the Social Security Act (42 U.S.C.

6 1395i–3(b)) is amended by adding at the end the

7 following new paragraph:

8 ‘‘(8) SUBMISSION OF DATA ON STAFFING LEV9 ELS.—

10 ‘‘(A) IN GENERAL.—A skilled nursing fa11 cility shall submit to the Secretary, at such

12 time as the Secretary shall specify and on a

13 standard reporting format developed by the

14 Secretary, data with respect to nursing staff

15 that—

16 ‘‘(i) includes the total number of nurs17 ing staff hours and coverage levels per

18 shift furnished by the facility to residents

19 for which payment is made under section

20 1888(e), broken down by total certified

21 nurse aide hours, total licensed practical or

22 vocational nurse hours, and total registered

23 nurse hours; and

24 ‘‘(ii) is attested to in writing by the

25 facility as accurate.
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1 ‘‘(B) PUBLICATION OF DATA.—The Sec2 retary shall provide for the publication on the

3 Internet Site of the Department of Health and

4 Human Services known as Nursing Home Com5 pare the facility-specific nursing staff informa6 tion described in subparagraph (A). The Sec7 retary shall update such information periodi8 cally.’’.

9 (2) INFORMATION CONCERNING PATIENT CLAS10 SIFICATION.—Section 1819(b)(4) of the Social Secu11 rity Act (42 U.S.C. 1395i–3(b)(4)) is amended by

12 adding at the end the following new subparagraph:

13 ‘‘(D) INFORMATION CONCERNING RESI14 DENTS.—The skilled nursing facility shall pro15 vide the Secretary, in such form and manner

16 and at such intervals as the Secretary may re17 quire, a classification of all residents of the

18 skilled nursing facility that accords with the

19 resident classification system described in sec20 tion 1888(e)(4)(G)(i), or such successor system

21 as the Secretary may identify.’’.

22 (b) MEDICAID.—

23 (1) DATA ON STAFFING LEVELS.—Section

24 1919(b) of the Social Security Act (42 U.S.C.
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1 1396r(b)) is amended by adding at the end the fol2 lowing new paragraph:

3 ‘‘(8) SUBMISSION OF DATA ON STAFFING LEV4 ELS.—

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

6 shall submit to the Secretary, at such time as

7 the Secretary shall specify and on a standard

8 reporting format developed by the Secretary,

9 data with respect to nursing staff that—

10 ‘‘(i) includes the total number of nurs11 ing staff hours and coverage levels per

12 shift furnished by the facility to residents

13 for which payment is made under the State

14 plan, broken down by total certified nurse

15 aide hours, total licensed practical or voca16 tional nurse hours, and total registered

17 nurse hours; and

18 ‘‘(ii) is attested to in writing by the

19 facility as accurate.

20 ‘‘(B) PUBLICATION OF DATA.—The Sec21 retary shall provide for the publication on the

22 Internet Site of the Department of Health and

23 Human Services known as Nursing Home Com24 pare the facility-specific nursing staff informa25 tion described in subparagraph (A). The Sec-
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1 retary shall update such information periodi2 cally.’’.

3 (2) INFORMATION CONCERNING PATIENT CLAS4 SIFICATION.—Section 1919(b)(4) of the Social Secu5 rity Act (42 U.S.C. 1395r(b)(4)) is amended by add6 ing at the end the following new subparagraph:

7 ‘‘(D) INFORMATION CONCERNING RESI8 DENTS.—The nursing facility shall provide the

9 Secretary, in such form and manner and at

10 such intervals as the Secretary may require, a

11 classification of all residents of the nursing fa12 cility that accords with the resident classifica13 tion system described in section

14 1888(e)(4)(G)(i), or such successor system as

15 the Secretary may identify.’’.

16 SEC. 7. INFORMATION ON NURSING FACILITY STAFFING.

17 (a) MEDICARE AMENDMENTS.—Section 1819(b) of

18 the Social Security Act (42 U.S.C. 1395i–3(b)), as amend19 ed by section 6(a), is further amended by adding at the

20 end the following new paragraph:

21 ‘‘(9) INFORMATION ON NURSE STAFFING.—A

22 skilled nursing facility shall post daily for each nurs23 ing unit of the facility and for each shift the current

24 number of licensed and unlicensed nursing staff di25 rectly responsible for resident care and the number
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1 of residents per unit and per shift. The information

2 shall be displayed in a uniform manner and in a

3 clearly visible place.’’.

4 (b) MEDICAID AMENDMENTS.—Section 1919(b) of

5 the Social Security Act (42 U.S.C. 1396r(b)), as amended

6 by section 6(b), is amended by adding at the end the fol7 lowing new paragraph:

8 ‘‘(9) INFORMATION ON NURSE STAFFING.—A

9 nursing facility shall post daily for each nursing unit

10 of the facility and for each shift the current number

11 of licensed and unlicensed nursing staff directly re12 sponsible for resident care and the number of resi13 dents per unit and per shift. The information shall

14 be displayed in a uniform manner and in a clearly

15 visible place.’’.

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

17 this section take effect on the first day of the first month

18 that begins at least 6 months after the date of the enact19 ment of this Act.

Æ