I
107TH CONGRESS
2D SESSION
H. R. 4715
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 HOUSE OF REPRESENTATIVES
MAY 14, 2002
Mr. WAXMAN (for himself, Mr. GEPHARDT, Mr. DINGELL, Mr. STARK, Mr.
BROWN of Ohio, Ms. SCHAKOWSKY, Mr. CARSON of Oklahoma, Ms. NOR-
TON, Mr. RODRIGUEZ, and Mr. MARKEY) introduced the following bill;
which was referred to the Committee on Energy and Commerce, and in
addition to the Committee on Ways and Means, for a period to be subse-
quently 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 establish minimum requirements for nurse staffing
in nursing facilities receiving payments under the Medi-
care or Medicaid Program.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; PURPOSE.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Nursing Home Staffing Improvement Act of 2002’’.
actment of this subparagraph, and
consistent with the provisions of this
clause, the Secretary shall promulgate
standards for minimum staffing levels
for facilities. Such standards shall
provide for sufficient staffing levels
during day, evening, and night shifts
to ensure that residents of nursing fa-
cilities receive the level of care nec-
essary to meet the objectives of sub-
section (b)(2), and shall provide for
appropriate adjustments to account
for resident case mix.
‘‘(II) MINIMUM
STANDARDS.—
Subject to subclause (III), standards
promulgated under subclause (I) shall
be, at a minimum, the HHS minimum
nurse staffing ratios (as defined in
clause (iii)).
‘‘(III) AUTHORITY TO PHASE IN
FACILITY COMPLIANCE WITH STAND-
ARDS.—If the Secretary determines
that compliance with the HHS min-
imum nurse staffing ratios is not fea-
sible for nursing facilities by the end
of the 2-year period applicable under
clause (i), the Secretary may delay the
implementation of the HHS minimum
nurse staffing ratios until the date
that is the end of the 5-year period
that begins on the date of the enact-
ment of this subparagraph. If the Sec-
retary delays implementation of the
HHS minimum nurse staffing ratios
under the previous sentence, the Sec-
retary shall phase in over such 5-year
period alternate minimum staffing
standards that gradually increase in
each of the years of the phase-in until
the such standards meet the HHS
minimum nurse staffing ratios.
‘‘(IV) 
COUNTING.—In 
deter-
mining compliance with the staffing
levels under this subparagraph, an in-
dividual may not be counted while
performing services that are not direct
nursing care, such as administrative
services, 
food 
preparation, 
house-
keeping, laundry, maintenance serv-
ices, or other activities that are not
direct nursing care.
‘‘(iii) HHS MINIMUM NURSE STAFF-
ING
RATIOS.—The term ‘HHS minimum
nurse staffing ratios’ means the minimum
staffing levels identified in the report to
Congress entitled ‘Appropriateness of Min-
imum Nurse Staffing Ratios in Nursing
Homes, Report to Congress: Phase II
Final’ submitted by the Secretary on
March 21, 2002, which require—
‘‘(I) from 2.4 to 2.8 hours of
care per resident per day by a cer-
tified nurse aide,
‘‘(II) from 1.15 to 1.3 hours of
care per resident per day by a licensed
practical nurse, a licensed vocational
nurse, or a registered nurse, plus
‘‘(III) from 0.55 to 0.75 hours of
care per resident per day by a reg-
istered nurse.
‘‘(iv) CONSTRUCTION.—
‘‘(I) NONPREEMPTION.—Nothing
in this subparagraph shall be con-
strued as prohibiting the Secretary or
a State (in the case of title XIX) from
imposing higher minimum staffing
levels on facilities than those imposed
under this subparagraph.
‘‘(II) 
MINIMUM
STANDARDS
ONLY.—Compliance with the staffing
requirements imposed under this sub-
paragraph alone shall not be con-
strued as complying with the require-
ment under paragraph (2) to provide
services to attain or maintain the
highest practicable physical, mental,
and psychosocial well-being of each
resident.
‘‘(III) 
SUPPLEMENTARY
RE-
QUIREMENTS.—The staffing require-
ments of this subparagraph are in ad-
dition to the requirements of subpara-
graph (C).’’.
(b) POSTING OF STAFFING INFORMATION.—
(1) IN GENERAL.—The first sentence of sub-
paragraph 
(A) 
of 
sections 
1819(b)(8) 
and
1919(b)(8) of the Social Security Act (42 U.S.C.
1395i–3(b)(8); 1396r(b)(8)) are each amended by
inserting before the period the following: ‘‘, a de-
scription of the minimum staffing requirements
under paragraph (4)(D), and the average number of
hours of nursing care that residents of the facility
have received for each of the four previous calendar
quarters’’.
(2) REPORTS.—Such sections are each amended
by adding at the end the following new subpara-
graph:
‘‘(C) REPORTS OF STAFFING DATA.—A fa-
cility shall maintain records on nurse staffing,
and shall submit such reports of such records
to the Secretary as the Secretary may require
for the administration and enforcement of this
section. Such records shall be reviewed for accu-
racy as part of a standard survey required
under subsection (g)(2)(A).’’.
SEC. 3. INCREASED RESOURCES.
(a) REINSTITUTION OF BOREN AMENDMENT PAY-
MENT METHODOLOGY.—
(1) IN GENERAL.—Section 1902(a)(13) of the
Social Security Act (42 U.S.C. 1396a(a)(13)) is
amended to read as follows:
‘‘(13) provide for payment of services through
the use of rates determined pursuant to the criteria
under this paragraph as in effect on August 1,
1997;’’.
(2) 
ESTABLISHMENT
OF
SAFE
HARBOR
RATES.—Section 1902 of such Act (42 U.S.C.
1396a) is amended by adding at the end the fol-
lowing: ‘‘The Secretary may, by regulation, promul-
gate standards or methodologies for determining
rates that comply with paragraph (13), and a State
that pays rates that meet such standards or meth-
odologies is deemed to be in compliance with para-
graph (13).’’.
(3) EFFECTIVE DATE.—The amendment made
by this subsection shall apply to services furnished
on or after the date that is one year after the date
of the enactment of this Act.
(b) PERMANENT 1.5 PERCENT INCREASE OF MED-
ICAID FMAP BEGINNING WITH FISCAL YEAR 2003.—
Section 1905(b) of the Social Security Act (42 U.S.C.
1396d(b)) is amended by adding at the end the following:
‘‘With respect to calendar quarters beginning after Octo-
ber 1, 2002, the Federal medical assistance percentage for
a State determined under the first sentence shall be in-
creased by 1.50 percentage points.’’.
(c) FINANCIAL ACCOUNTABILITY.—
(1) IN
GENERAL.—Sections 1819(g)(2) and
1919(g)(2) of the Social Security Act (42 U.S.C.
1395i–3(g)(2); 1396r(g)(2)) are each amended—
(A) by redesignating subparagraphs (C),
(D), and (E) as subparagraphs (D), (E), and
(F); and
(B) by inserting after subparagraph (B)
the following new subparagraph:
‘‘(C) 
FINANCIAL
ACCOUNTABILITY.—A
standard or an extended survey may include an
examination of the financial records of a facility
to determine whether payments made to the fa-
cility under this section for services furnished to
residents are being used in a manner consistent
with this section.’’.
(2) EFFECTIVE DATE.—The amendments made
by paragraph (1) shall apply to surveys conducted
on or after the date of the enactment of this Act.
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