II 

108TH CONGRESS 

1ST SESSION S. 1988

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 SENATE OF THE UNITED STATES 

DECEMBER 9, 2003

Mr. DASCHLE (for Mr. EDWARDS) introduced the following bill; which was 

read twice and referred to the Committee on Finance 

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,

3 SECTION 1. SHORT TITLE; PURPOSE. 

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

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

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

7 the quality of care received by residents of nursing facili8 ties through the implementation of the minimum nurse 
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•S 1988 IS 

1 staffing levels identified by the Secretary of Health and 

2 Human Services in a report to Congress submitted on 

3 March 21, 2002. 

4 SEC. 2. IMPLEMENTATION OF NURSE STAFFING STAND5 ARDS. 

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

7 1919(b)(4) of the Social Security Act (42 U.S.C. 1395i–

8 3(b)(4); 1396r(b)(4)) are each amended by adding at the 

9 end the following new subparagraph: 

10 ‘‘(D) MINIMUM STAFFING REQUIRE11 MENTS.—

12 ‘‘(i) DEADLINE FOR COMPLIANCE

13 WITH MINIMUM STANDARDS.—With respect 

14 to facility services provided after the date 

15 that is the end of the 2-year period begin16 ning on the date of the enactment of this 

17 subparagraph, a facility shall comply with 

18 the minimum staffing levels promulgated 

19 by the Secretary under clause (ii). 

20 ‘‘(ii) FINAL REGULATIONS.—

21 ‘‘(I) IN GENERAL.—Not later 

22 than 1 year after the date of the en23 actment of this subparagraph, and 

24 consistent with the provisions of this 

25 clause, the Secretary shall promulgate 
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•S 1988 IS 

1 standards for minimum staffing levels 

2 for facilities. Such standards shall 

3 provide for sufficient staffing levels 

4 during day, evening, and night shifts 

5 to ensure that residents of nursing fa6 cilities receive the level of care nec7 essary to meet the objectives of sub8 section (b)(2), and shall provide for 

9 appropriate adjustments to account 

10 for resident case mix. 

11 ‘‘(II) MINIMUM STANDARDS.—

12 Subject to subclause (III), standards 

13 promulgated under subclause (I) shall 

14 be, at a minimum, the HHS minimum 

15 nurse staffing ratios (as defined in 

16 clause (iii)). 

17 ‘‘(III) AUTHORITY TO PHASE IN

18 FACILITY COMPLIANCE WITH STAND19 ARDS.—If the Secretary determines 

20 that compliance with the HHS min21 imum nurse staffing ratios is not fea22 sible for nursing facilities by the end 

23 of the 2-year period applicable under 

24 clause (i), the Secretary may delay the 

25 implementation of the HHS minimum 
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1 nurse staffing ratios until the date 

2 that is the end of the 5-year period 

3 that begins on the date of the enact4 ment of this subparagraph. If the Sec5 retary delays implementation of the 

6 HHS minimum nurse staffing ratios 

7 under the previous sentence, the Sec8 retary shall phase in over such 5-year 

9 period alternative minimum staffing 

10 standards that gradually increase in 

11 each of the years of the phase-in until 

12 the such standards meet the HHS 

13 minimum nurse staffing ratios. 

14 ‘‘(IV) COUNTING.—In deter15 mining compliance with the staffing 

16 levels under this subparagraph, an in17 dividual may not be counted while 

18 performing services that are not direct 

19 nursing care, such as administrative 

20 services, food preparation, house21 keeping, laundry, maintenance serv22 ices, or other activities that are not 

23 direct nursing care. 

24 ‘‘(iii) HHS MINIMUM NURSE STAFF25 ING RATIOS.—The term ‘HHS minimum 
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1 nurse staffing ratios’ means the minimum 

2 staffing levels identified in the report to 

3 Congress entitled ‘Appropriateness of Min4 imum Nurse Staffing Ratios in Nursing 

5 Homes, Report to Congress: Phase II 

6 Final’ submitted by the Secretary on 

7 March 21, 2002, which require—

8 ‘‘(I) from 2.4 to 2.8 hours of 

9 care per resident per day by a cer10 tified nurse aide, and 

11 ‘‘(II) from 1.15 to 1.3 hours of 

12 care per resident per day by a licensed 

13 practical nurse, a licensed vocational 

14 nurse, or a registered nurse, of which 

15 from 0.55 to 0.75 hours of care per 

16 resident per day shall be provided by 

17 a registered nurse. 

18 ‘‘(iv) CONSTRUCTION.—

19 ‘‘(I) NONPREEMPTION.—Nothing 

20 in this subparagraph shall be con21 strued as prohibiting the Secretary or 

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

23 imposing higher minimum staffing 

24 levels on facilities than those imposed 

25 under this subparagraph.
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1 ‘‘(II) MINIMUM STANDARDS

2 ONLY.—Compliance with the staffing 

3 requirements imposed under this sub4 paragraph alone shall not be con5 strued as complying with the require6 ment under paragraph (2) to provide 

7 services to attain or maintain the 

8 highest practicable physical, mental, 

9 and psychosocial well-being of each 

10 resident. 

11 ‘‘(III) SUPPLEMENTARY RE12 QUIREMENTS.—The staffing require13 ments of this subparagraph are in ad14 dition to the requirements of subpara15 graph (C).’’. 

16 (b) POSTING OF STAFFING INFORMATION.—

17 (1) IN GENERAL.—The first sentence of sub18 paragraph (A) of sections 1819(b)(8) and 

19 1919(b)(8) of the Social Security Act (42 U.S.C. 

20 1395i–3(b)(8); 1396r(b)(8)) are each amended by 

21 inserting before the period the following: ‘‘, a de22 scription of the minimum staffing requirements 

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

24 hours of nursing care that residents of the facility 
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1 have received for each of the four previous calendar 

2 quarters’’. 

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

4 by adding at the end the following new subpara5 graph: 

6 ‘‘(C) REPORTS OF STAFFING DATA.—A fa7 cility shall maintain records on nurse staffing, 

8 and shall submit such reports of such records 

9 to the Secretary as the Secretary may require 

10 for the administration and enforcement of this 

11 section. Such records shall be reviewed for accu12 racy as part of a standard survey required 

13 under subsection (g)(2)(A).’’. 

14 SEC. 3. INCREASED RESOURCES. 

15 (a) REINSTITUTION OF BOREN AMENDMENT PAY16 MENT METHODOLOGY.—

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

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

19 amended to read as follows: 

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

21 the use of rates determined pursuant to the criteria 

22 under this paragraph as in effect on August 1, 

23 1997;’’. 

24 (2) ESTABLISHMENT OF SAFE HARBOR

25 RATES.—Section 1902 of such Act (42 U.S.C. 
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1 1396a) is amended by adding at the end the fol2 lowing: ‘‘The Secretary may, by regulation, promul3 gate standards or methodologies for determining 

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

5 that pays rates that meet such standards or meth6 odologies is deemed to be in compliance with para7 graph (13).’’. 

8 (3) EFFECTIVE DATE.—The amendment made 

9 by this subsection shall apply to services furnished 

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

11 of the enactment of this Act. 

12 (b) PERMANENT 1.5 PERCENT INCREASE OF MED13 ICAID FMAP BEGINNING WITH FISCAL YEAR 2004.—

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

15 1396d(b)) is amended by adding at the end the following: 

16 ‘‘With respect to calendar quarters beginning after Octo17 ber 1, 2003, the Federal medical assistance percentage for 

18 a State determined under the first sentence shall be in19 creased by 1.50 percentage points.’’. 

20 (c) FINANCIAL ACCOUNTABILITY.—

21 (1) IN GENERAL.—Sections 1819(g)(2) and 

22 1919(g)(2) of the Social Security Act (42 U.S.C. 

23 1395i–3(g)(2); 1396r(g)(2)) are each amended—
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1 (A) by redesignating subparagraphs (C), 

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

3 (F); and 

4 (B) by inserting after subparagraph (B) 

5 the following new subparagraph: 

6 ‘‘(C) FINANCIAL ACCOUNTABILITY.—A 

7 standard or an extended survey may include an 

8 examination of the financial records of a facility 

9 to determine whether payments made to the fa10 cility under this section for services furnished to 

11 residents are being used in a manner consistent 

12 with this section.’’. 

13 (2) COMPOSITION OF MULTIDISCIPLINARY

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

15 1919(g)(2)(E)(i) of the Social Security Act (42 

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

17 each amended by inserting after the period the fol18 lowing: ‘‘This multidisciplinary team may include 

19 professionals trained in financial accounting and au20 diting.’’

21 (3) EFFECTIVE DATE.—The amendments made 

22 by paragraph (1) shall apply to surveys conducted 

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

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