I 
109TH CONGRESS 
1ST SESSION H. R. 4293 
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 
NOVEMBER 10, 2005 
Mr. WAXMAN (for himself, Mr. DINGELL, Mr. RANGEL, Mr. BROWN of Ohio, 
Mr. STARK, Mrs. CAPPS, Ms. SCHAKOWSKY, Mr. BACA, Ms. BALDWIN, 
Mr. BERMAN, Mr. BRADY of Pennsylvania, Ms. CORRINE BROWN of Flor-
ida, Mr. CHANDLER, Mr. CLAY, Mr. FRANK of Massachusetts, Mr. 
GRIJALVA, Mr. GUTIERREZ, Mr. HINCHEY, Mr. HOLDEN, Ms. KAPTUR, 
Mr. KILDEE, Mr. KUCINICH, Mrs. MALONEY, Mr. MARKEY, Mrs. MCCAR-
THY, Mr. MCDERMOTT, Mr. MCNULTY, Mr. MEEHAN, Mr. MOORE of 
Kansas, Ms. NORTON, Mr. OWENS, Mr. PALLONE, Ms. ROYBAL-ALLARD, 
Mr. RUSH, Mr. SANDERS, Mr. THOMPSON of Mississippi, Mr. VAN 
HOLLEN, Ms. WATERS, Mr. WEXLER, Mr. WYNN, Ms. SOLIS, and Mr. 
HOLT) 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 subsequently determined by the Speaker, 
in each case for consideration of such provisions as fall within the juris-
diction 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 Act of 2005’’. 
(b) PURPOSE.—The purpose of this Act is to improve 
the quality of care received by residents of nursing facili-
ties through the implementation of the minimum nurse 
staffing levels identified by the Secretary of Health and 
Human Services in a report to Congress submitted on 
March 21, 2002. 
SEC. 2. IMPLEMENTATION OF NURSE STAFFING STAND-
ARDS. 
(a) 
IN
GENERAL.—Sections 
1819(b)(4) 
and 
1919(b)(4) of the Social Security Act (42 U.S.C. 1395i– 
3(b)(4); 1396r(b)(4)) are each amended by adding at the 
end the following new subparagraph: 
‘‘(D) 
MINIMUM
STAFFING
REQUIRE-
MENTS.— 
‘‘(i) DEADLINE
FOR
COMPLIANCE 
WITH MINIMUM STANDARDS.—With respect 
to facility services provided after the date 
that is the end of the 2-year period begin-
ning on the date of the enactment of this 
subparagraph, a facility shall comply with 
the minimum staffing levels promulgated 
by the Secretary under clause (ii). 
‘‘(ii) FINAL REGULATIONS.—
‘‘(I) IN
GENERAL.—Not later 
than 1 year after the date of the en-
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 alternative minimum staffing 
standards that gradually increase in 
each of the years of the phase-in until 
such standards meet the HHS min-
imum 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; and 
‘‘(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 2006.— 
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, 2005, 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) 
COMPOSITION
OF
MULTIDISCIPLINARY 
TEAM.—Sections 
1819(g)(2)(E)(i) 
and 
1919(g)(2)(E)(i) of the Social Security Act (42 
U.S.C. 1395i–3(g)(2)(E)(i); 1396r(g)(2)(E)(i)) are 
each amended by inserting after the period the fol-
lowing: ‘‘This multidisciplinary team may include 
professionals trained in financial accounting and au-
diting.’’
(3) 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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