I
106TH CONGRESS
2D SESSION
H. R. 5243
To establish a program to provide grants to States to test innovative ways
to increase nursing home staff levels, reduce turnover, and improve
quality of care for residents in nursing homes, and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
SEPTEMBER 21, 2000
Mr. HOLT (for himself, Mr. GEPHARDT, Mr. WAXMAN, and Mr. STARK) intro-
duced the following bill; which was referred to the Committee on Com-
merce, and in addition to the Committee on Ways and Means, for a pe-
riod to be subsequently determined by the Speaker, in each case for con-
sideration of such provisions as fall within the jurisdiction of the com-
mittee concerned
A BILL
To establish a program to provide grants to States to test
innovative ways to increase nursing home staff levels,
reduce turnover, and improve quality of care for resi-
dents in nursing homes, and for other purposes.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; REFERENCES IN ACT.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Nursing Home Staffing and Quality Improvement Act of
2000’’.
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(b) REFERENCES.—Except where otherwise specifi-
cally provided, references in this Act shall be considered
to be made to the Social Security Act, or to a section or
other provision thereof, and references to the ‘‘Secretary’’
shall be considered to be made to the Secretary of Health
and Human Services.
SEC. 2. GRANTS TO STATES FOR IMPROVEMENTS IN NURS-
ING HOME STAFFING AND QUALITY.
(a) SECRETARY’S AUTHORITY TO AWARD GRANTS.—
The Secretary shall establish a program of competitive
grants to States, in accordance with the provisions of this
section, for the purpose of improving the quality of care
furnished in nursing homes operating in the State.
(b) APPLICATIONS AND ELIGIBILITY FOR GRANTS.—
(1) INITIAL APPLICATION.—A State seeking a
grant to conduct a project under this section shall
submit an application containing such information
and assurances as the Secretary may require,
including—
(A) a commitment to submit annual re-
ports describing the State’s progress in increas-
ing staffing levels and making other quality im-
provements in nursing homes in the State; and
(B) a description of a plan for evaluation
of the activities carried out under the grant, in-
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cluding a plan for measurement of progress to-
ward the goals and objectives of the program,
consistent with the principles of the Govern-
ment Performance and Results Act.
(2) CONSULTATION WITH PUBLIC.—Before sub-
mitting an application for a grant under this section,
States shall solicit and consider the views of mem-
bers of the public, nursing home residents or their
representatives, and other persons concerned with
the administration of nursing homes within the
State with respect to the design of the proposed
State program.
(3) ELIGIBILITY.—
(A) INITIAL ELIGIBILITY.—A State shall
not be eligible for a grant award under this sec-
tion unless it makes assurances satisfactory to
the Secretary that the skilled nursing facilities
(as defined in section 1819(a)) and nursing fa-
cilities (as defined in section 1919(a)) within
the State will reach or exceed the minimum
staff level described in subsection (d)(2) within
two years after enactment of this Act and will
maintain such level throughout the remainder
of the grant program.
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(B) CONTINUING
ELIGIBILITY.—A State
shall not be eligible for the continuation of
grant funding under a multi-year grant under
this section unless the State demonstrates to
the Secretary’s satisfaction that it continues to
meet the requirement described in subpara-
graph (A) and has made sufficient progress in
meeting the goals described in its grant applica-
tion.
(c) USE OF GRANT FUNDS.—Funds received by a
State under this section may be provided to entities in-
cluding nursing homes, labor management partnerships,
and educational institutions, and may be used for any or
all of the following purposes:
(1) To enable a nursing home to recruit addi-
tional nursing staff or to retain existing nursing
staff (including through the use of reasonable finan-
cial incentives or reasonable benefit enhancements).
(2) To increase education and training of nurs-
ing staff (including designing or implementing pro-
grams to promote the career advancement of cer-
tified nurse aides).
(3) To provide bonuses to nursing homes meet-
ing State quality standards or avoiding serious qual-
ity violations for a period of one or more years.
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(4) Such other nursing home staffing and qual-
ity improvement initiatives as the Secretary may ap-
prove.
(d) DISTRIBUTION OF FUNDS.—
(1) IN GENERAL.—Subject to subsection (b), in
awarding grants under this section, the Secretary
shall award no more than 25 percent of the funds
to States in which, as of the date of the enactment
of this section, skilled nursing facilities (as defined
in section 1819(a)) and nursing facilities (as defined
in section 1919(a)) have reached or exceeded the
minimum staff level specified in paragraph (2) (as
determined by the Secretary).
(2) MINIMUM NURSING HOME STAFF LEVEL.—
(A) IN
GENERAL.—Subject to subpara-
graph (B), for purposes of subsection (b) and
paragraph (1), the level specified in this para-
graph for a skilled nursing facility or nursing
facility is a staff level sufficient to ensure that
each resident receives from a certified nurse
aide at least 2 hours per day of direct care (in-
cluding repositioning the resident and changing
wet clothes, assisting with feeding, exercise, and
toileting, and working to enhance a resident’s
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independence with respect to activities of daily
living).
(B) SECRETARY’S
AUTHORITY
TO
IN-
CREASE
MINIMUM
STAFF
LEVEL.—The Sec-
retary may establish a minimum staff level that
is higher than that specified in subparagraph
(A). Any such revised staff level shall be effec-
tive no earlier than six months after the date on
which Secretary provides notice to States of the
new requirement.
(3) MULTI-YEAR
GRANT
FUNDS.—The Sec-
retary shall award any multi-year grant under this
section from amounts appropriated (or available pur-
suant to subsection (e)(2)) for the first fiscal year
of the grant.
(e) APPROPRIATIONS AND AVAILABILITY OF CIVIL
MONEY PENALTY (CPM) COLLECTIONS.—
(1) APPROPRIATIONS.—There are appropriated
for all costs to the Secretary for carrying out the
program under this section $200,000,000 for each of
fiscal years 2001 through 2005, such funds to re-
main available to the Secretary through the end of
the first succeeding fiscal year.
(2) AVAILABILITY OF CMP COLLECTIONS.—In
addition to the amounts appropriated pursuant to
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paragraph (1), there shall be available to the Sec-
retary for such costs for such fiscal years any
amounts deposited in the Nursing Facility Civil
Money Penalties Collection Account established
under section 4.
SEC. 3. ENHANCED NURSING FACILITY REPORTING RE-
QUIREMENTS.
(a) MEDICARE.—
(1) SUBMISSION
OF
NURSING
STAFF
LEVEL
DATA
TO
THE
SECRETARY.—Section 1819(b) (42
U.S.C. 1395i–3(b)) is amended by adding at the end
the following new paragraph:
‘‘(8) DATA ON STAFFING LEVELS.—
‘‘(A) 
SUBMISSION
TO
SECRETARY.—A
skilled nursing facility shall submit to the Sec-
retary, in such form and manner and at such
intervals as the Secretary may require, data
with respect to nursing staff of the facility.
Such data shall include the total number of
nursing staff hours furnished during the period
specified by the Secretary (including totals for
each shift worked during such period) by the
facility to residents for which payment is made
under section 1888(e), broken down by total
certified nurse aide hours, total licensed prac-
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tical or vocational nurse hours, and total reg-
istered nurse hours, and shall also include the
average wage rate for each class of nursing
staff employed by the facility.
‘‘(B) PUBLICATION.—The Secretary shall
provide for the publication on the Internet Site
of the Department of Health and Human Serv-
ices known as Nursing Home Compare the fa-
cility-specific nursing staff information collected
pursuant to subparagraph (A). The Secretary
shall update such information periodically.’’.
(2) POSTING OF INFORMATION ON NURSING FA-
CILITY
STAFFING.—Section 1819(b) (42 U.S.C.
1395i–3(b)), as amended by paragraph (1), is fur-
ther amended by adding at the end the following
new paragraph:
‘‘(9) INFORMATION ON NURSE STAFFING.—
‘‘(A) IN GENERAL.—A skilled nursing fa-
cility shall post daily for each nursing unit of
the facility and for each shift the current num-
ber of licensed and unlicensed nursing staff di-
rectly responsible for resident care. The infor-
mation shall be displayed in a uniform manner
(as specified by the Secretary) and in a clearly
visible place.
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‘‘(B) PUBLICATION
OF
DATA.—A skilled
nursing facility shall, upon request, make avail-
able to the public the nursing staff data de-
scribed in subparagraph (A).’’.
(3) INFORMATION CONCERNING PATIENT CLAS-
SIFICATION.—Section 1819(b)(4)(C) (42 U.S.C.
1395i–3(b)(4)(C)) is amended by adding at the end
the following new clause:
‘‘(iii) 
INFORMATION
CONCERNING
RESIDENTS.—The skilled nursing facility
shall provide the Secretary, in such form
and manner and at such intervals as the
Secretary may require, a classification of
all residents of the skilled nursing facility
that accords with the patient classification
system 
described 
in 
section
1888(e)(3)(B)(ii), or such successor system
as the Secretary may identify.’’.
(b) MEDICAID.—
(1) IN GENERAL.—Section 1919(b) (42 U.S.C.
1396r) is amended by adding at the end the fol-
lowing new paragraph:
‘‘(8) DATA ON STAFFING LEVELS.—
‘‘(A) 
SUBMISSION
TO
SECRETARY.—A
nursing facility shall submit to the Secretary, in
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such form and manner and at such intervals as
the Secretary may require, data with respect to
nursing staff of the facility. Such data shall in-
clude the total number of nursing staff hours
furnished during the period specified by the
Secretary (including totals for each shift
worked during such period) by the facility to
residents for which payment is made under this
title, broken down by total certified nurse aide
hours, total licensed practical or vocational
nurse hours, and total registered nurse hours,
and shall also include the average wage rate for
each class of nursing staff employed by the fa-
cility.
‘‘(B) PUBLICATION.—The Secretary shall
provide for the publication on the Internet Site
of the Department of Health and Human Serv-
ices known as Nursing Home Compare the fa-
cility-specific nursing staff information collected
pursuant to subparagraph (A). The Secretary
shall update such information periodically.’’.
(2) POSTING OF INFORMATION ON NURSING FA-
CILITY
STAFFING.—Section 1919(b) (42 U.S.C.
1395r(b)), as amended by paragraph (1), is further
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amended by adding at the end the following new
paragraph:
‘‘(9) INFORMATION ON NURSE STAFFING.—
‘‘(A) IN
GENERAL.—A nursing facility
shall post daily for each nursing unit of the fa-
cility and for each shift the current number of
licensed and unlicensed nursing staff directly
responsible for resident care. The information
shall be displayed in a uniform manner (as
specified by the Secretary) and in a clearly visi-
ble place.
‘‘(B) PUBLICATION OF DATA.—A nursing
facility shall, upon request, make available to
the public the nursing staff data described in
subparagraph (A).’’.
(3) INFORMATION CONCERNING PATIENT CLAS-
SIFICATION.—Section 1919(b)(4)(C) (42 U.S.C.
1396r(b)(4)(C)) is amended by adding at the end
the following new clause:
‘‘(iv) 
INFORMATION
CONCERNING
RESIDENTS.—The nursing facility shall
provide the Secretary, in such form and
manner and at such intervals as the Sec-
retary may require, a classification of all
residents of the nursing facility that ac-
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cords with the patient classification system
described in section 1888(e)(3)(B)(ii), or
such successor system as the Secretary
may identify.’’.
SEC. 4. NURSING FACILITY CIVIL MONEY PENALTY COL-
LECTIONS.
(a) ESTABLISHMENT OF NURSING FACILITY CIVIL
MONEY
PENALTY
COLLECTIONS
ACCOUNT.—Section
1128A (42 U.S.C. 1320a–7a) is amended by adding at
the end the following new subsection:
‘‘(o) ESTABLISHMENT OF NURSING FACILITY CIVIL
MONEY PENALTY COLLECTIONS ACCOUNT.—There is
hereby established an account to be known as the ‘‘Nurs-
ing Facility Civil Money Penalties Collection Account’’
(hereafter in this subsection referred to as the ‘‘Ac-
count’’). Notwithstanding any other provision of law, there
shall be deposited into the Account the Secretary’s share
of any civil monetary penalties collected under sections
1819 and 1919, all such amounts to be available without
fiscal year limitation for repaying the Secretary’s share
of amounts owed to nursing facilities or skilled nursing
facilities pursuant to the final sentence of sections
1819(h)(2)(B)(ii) and 1919(h)(2)(B)(ii), and for award-
ing grants under section 2 of the Nursing Home Staffing
and Quality Improvement Act of 2000.’’.
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(b) 
AUTHORITY
TO
COLLECT
CMPS 
IMME-
DIATELY.—
(1) MEDICARE.—Section 1819(h)(2)(B)(ii) (42
U.S.C. 1395i–3(h)(2)(B)(ii)) is amended by insert-
ing before the final period ‘‘, except that, notwith-
standing section 1128A(c)(2) or any other provision
of law, the Secretary, upon determining that a civil
money penalty should be imposed against a skilled
nursing facility pursuant to this paragraph, shall
take immediate action to collect such penalty (except
where the Secretary finds that such action could
jeopardize the health or welfare of residents of the
skilled nursing facility). In collecting such penalty,
the Secretary may deduct the amount of the penalty
from amounts otherwise payable to the facility under
this title or take such other actions as the Secretary
considers appropriate. If the Secretary’s imposition
of a penalty under this paragraph is set aside, in
whole or in part, as a result of a hearing under sec-
tion 1128A(c)(2) (or an appeal therefrom) or by a
court of competent jurisdiction, and the Secretary
elects not to pursue an appeal of such judgment; or
has exhausted all appeals, the Secretary shall repay
any amount owed to the skilled nursing facility with
accrued interest.’’
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(2) MEDICAID.—Section 1919(h)(3)(B)(ii) (42
U.S.C. 1396r(h)(3)(B)(ii)) is amended by inserting
before the final period ‘‘, except that, notwith-
standing section 1128A(c)(2) or any other provision
of law, the Secretary, upon determining that a civil
money penalty should be imposed against a nursing
facility pursuant to this paragraph, shall take imme-
diate action to collect the penalty (except where the
Secretary finds that such action could jeopardize the
health or welfare of residents of the nursing facility).
In collecting such penalty, the Secretary may direct
the State to deduct the amount of the penalty from
amounts otherwise payable to the nursing facility
under this title or take such other actions as the
Secretary, in consultation with the State, considers
appropriate. If the Secretary’s imposition of a pen-
alty under this paragraph is set aside, in whole or
in part, as a result of a hearing under section
1128A(c)(2) (or an appeal therefrom) or by a court
of competent jurisdiction, and the Secretary elects
not to pursue an appeal of such judgment, or has
exhausted all appeals, the Secretary shall repay, or
shall direct the State to repay, any amount owed to
the nursing facility with accrued interest.’’
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