I
106TH CONGRESS
2D SESSION
H. R. 4949
To amend title XIX of the Social Security Act to improve the quality of
care furnished in nursing homes.
IN THE HOUSE OF REPRESENTATIVES
JULY 25, 2000
Mr. WAXMAN (for himself, Mr. GEPHARDT, Mr. DINGELL, Mr. STARK, Mr.
BROWN of Ohio, Mr. GEORGE MILLER of California, Ms. SCHAKOWSKY,
Mr. FORBES, Mr. HOLT, Mr. LANTOS, Ms. LEE, Mr. BLAGOJEVICH, Mr.
HINCHEY, and Mr. WYNN) introduced the following bill; which was re-
ferred to the Committee on Commerce
A BILL
To amend title XIX of the Social Security Act to improve
the quality of care furnished in nursing homes.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) IN GENERAL.—This Act may be cited as the
‘‘Nursing Home Quality Protection Act’’.
(b) TABLE OF CONTENTS.—The table of contents of
this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Increased sanctions for substandard care furnished in nursing homes.
Sec. 3. Increased resources to improve the quality of care furnished in nursing
homes.
Sec. 4. Increased public disclosure of nursing home conditions.
SEC. 2. INCREASED SANCTIONS FOR SUBSTANDARD CARE
FURNISHED IN NURSING HOMES.
(a) IN GENERAL.—Section 1919 of the Social Secu-
rity Act (42 U.S.C. 1396r) is amended—
(1) by redesignating subsection (i) as subsection
(j); and
(2) by inserting after subsection (h) the fol-
lowing new subsection:
‘‘(i) REFUND
OF FEDERAL MONEYS
FOR SUB-
STANDARD NURSING CARE.—
‘‘(1) IN GENERAL.—From amounts paid under
a State plan to a nursing facility, the nursing facil-
ity shall refund to the Secretary (for deposit in the
Account established in subsection (j)) for deficiencies
identified in a survey under subsection (g) the fol-
lowing amounts:
‘‘(A) $2,000 for each deficiency that had
the potential to cause more than minimal harm
to a resident of the nursing facility.
‘‘(B) $10,000 for each deficiency that
caused actual harm to a resident of the nursing
facility.
‘‘(C) $25,000 for each deficiency that
placed a resident of the nursing facility in im-
mediate jeopardy.
Amounts under this subparagraph shall be adjusted
annually to account for inflation in the manner pro-
vided for in section 1924(g).
‘‘(2) DEADLINE FOR SUBSTANDARD CARE RE-
FUND.—Payment of the amounts payable by a nurs-
ing facility to the Secretary under paragraph (1)
shall be made not later than 30 days after the nurs-
ing facility receives notice of the deficiencies and the
amount of substandard care refund due.
‘‘(3) WITHHOLDING OF PAYMENTS FOR FAIL-
URE TO PAY A SUBSTANDARD CARE REFUND TO THE
SECRETARY.—In the case of a nursing facility that
does not pay a substandard care refund required
under paragraph (1), in order to ensure that pay-
ments under the State plan to the facility are re-
duced by the amount of substandard care refund
due from the facility, the Secretary shall withhold
from payments attributable to this section the
amount of such substandard care refund.
‘‘(4) APPEAL.—
‘‘(A) IN
GENERAL.—The Secretary shall
establish a procedure for a nursing facility to
appeal to the Secretary a substandard care re-
fund paid or an amount withheld under this
paragraph.
‘‘(B) REPAYMENTS BY THE SECRETARY.—
If a nursing facility is successful on appeal, the
Secretary shall pay to the nursing facility an
amount equal to the amount of the substandard
care refund paid under paragraph (1), or the
amount withheld under paragraph (3), or both,
if applicable, plus interest accruing on such
amount at the rate applicable under section
1903(d)(5).
‘‘(5) RELATION TO OTHER SANCTIONS.—
‘‘(A) IN
GENERAL.—A substandard care
refund paid by or an amount withheld from a
nursing facility for a deficiency under this
paragraph—
‘‘(i) shall not affect the authority of a
State or the Secretary to take enforcement
actions or impose sanctions against the
nursing facility under any other provision
of law with respect to the deficiency;
‘‘(ii) shall be deducted from civil
money penalties assessed by the Secretary
with respect to the deficiency under other
provisions of this Act; and
‘‘(iii) shall not affect any remedy
available to an individual at common law.
‘‘(B) PRESERVING
RIGHT
TO
APPEAL.—
The failure of a nursing facility to appeal a
substandard care refund paid by or amount
withheld from the facility for a deficiency under
this paragraph shall have no effect on the right
of the facility to appeal any enforcement action
taken or sanction imposed by the Secretary
with respect to the deficiency under other provi-
sions of this Act.’’.
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall apply with respect to surveys con-
ducted on or after the date that is one year after the date
of the enactment of this Act, without regard to whether
or not final regulations to carry out such amendments
have been promulgated by such date.
SEC. 3. INCREASED RESOURCES TO IMPROVE THE QUALITY
OF CARE FURNISHED IN NURSING HOMES.
(a) REINSTITUTION OF BOREN AMENDMENT PAY-
MENT METHODOLOGY.—
(1) PURPOSE.—In 1997, Congress repealed the
Boren amendment, which required that the States
make reasonable and adequate payments to nursing
homes and other health care facilities in order to
provide quality care to residents. The purpose of this
section is to restore the Boren amendment so that
those facilities can provide better care to residents.
(2) PROVISION FOR PAYMENT OF REASONABLE
AND ADEQUATE COSTS.—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 under this paragraph as
in effect on August 1, 1997;’’.
(3) EFFECTIVE DATE.—The amendment made
by paragraph (2) shall apply to services furnished on
or after the date that is one year after the date of
the enactment of this Act.
(b) GRANT PROGRAM TO IMPROVE QUALITY
OF
CARE FURNISHED IN NURSING HOMES.—Section 1919 of
the Social Security Act (42 U.S.C. 1396r), as amended
by section 2(a), is further amended—
(1) by redesignating subsection (j) as sub-
section (k); and
(2) by inserting after subsection (i) the fol-
lowing new subsection:
‘‘(j) NURSING FACILITY QUALITY IMPROVEMENT AC-
COUNT.—
‘‘(1) ESTABLISHMENT
OF
NURSING
FACILITY
QUALITY IMPROVEMENT ACCOUNT.—
‘‘(A) IN GENERAL.—There is hereby cre-
ated on the books of the Treasury an expendi-
ture account to be known as the ‘Nursing Facil-
ity Quality Improvement Account’ (in this sub-
section referred to as the ‘Account’).
‘‘(B) DEPOSIT
OF
FUNDS
IN
THE
AC-
COUNT.—The Secretary shall deposit in the
Account—
‘‘(i) all substandard care refunds from
nursing facilities under subsection (i)(1);
and
‘‘(ii) amounts withheld under sub-
section (i)(3).
‘‘(C) APPROPRIATED AMOUNTS FROM SUB-
STANDARD CARE REFUNDS.—There are hereby
appropriated to the Account such amounts as
the Secretary deposits to the Account under
this paragraph.
‘‘(2) GRANTS FOR IMPROVEMENT OF QUALITY
OF CARE.—
‘‘(A) IN
GENERAL.—Subject to the suc-
ceeding provisions of this paragraph, from
amounts available in the Account, the Secretary
shall make grants to States for the purpose of
improving the quality of care furnished in nurs-
ing facilities operating in the State.
‘‘(B) USE
OF
GRANT
FUNDS.—Grants
made available to States under subparagraph
(A) may be used for any or all of the following
specified purposes:
‘‘(i) To enable a nursing facility to re-
cruit additional nursing staff or to retain
existing nursing staff (including through
the use of financial incentives).
‘‘(ii) To increase education and train-
ing of nursing staff.
‘‘(iii) To provide incentives to increase
the level of nursing staff in a nursing facil-
ity.
‘‘(iv) Any other purpose that the Sec-
retary determines is likely to improve the
quality of care furnished to residents of a
nursing facility.
‘‘(C) TERMS AND CONDITIONS.—The Sec-
retary shall establish such terms and conditions
as the Secretary determines to be appropriate
for the receipt of grant funds under this para-
graph. Such terms and conditions shall include
the following requirements:
‘‘(i) A State shall develop a plan for
the use of grant funds.
‘‘(ii) In developing the plan required
under clause (i), the State shall consult
with representatives of nursing facility
residents, of nursing facilities, of nursing
staff, and of other interested parties, and
shall provide for an opportunity for public
comment.
‘‘(iii) The State shall submit to the
Secretary annual reports on the use of
grant funds under the plan.
‘‘(D) AGGREGATE
AMOUNT
OF
GRANT
FUNDS FOR STATES.—The amount of a grant
to a State under this subsection may not exceed
the aggregate amount of substandard care re-
funds (under subsection (i)) from nursing facili-
ties operating in the State.
‘‘(E) NONPARTICIPATION
BY
STATES.—
Notwithstanding subparagraph (D), if a State
does not receive a grant under this subsection,
the Secretary may redistribute, in a manner
consistent with section 2104(f), the sub-
standard care refunds received from nursing fa-
cilities in that State to other States.
‘‘(F) LIMITATIONS
ON
USE
OF
GRANT
AMOUNTS.—A State may not use amounts
made available under a grant under this
paragraph—
‘‘(i) to satisfy any requirement for the
expenditure of non-Federal funds as a con-
dition for the receipt of Federal funds; or
‘‘(ii) to make payments to a nursing
facility that is not in compliance with Fed-
eral labor and employment laws or that
has a pattern of violations of such laws.
Amounts made available under a grant under
this paragraph shall be in addition to, and may
not be used to supplant, any funds that are or
would otherwise be expended under any Fed-
eral, State, or local law by a State or local gov-
ernment.
‘‘(G) DEFINITION.—In this subsection and
subsection (g)(5)(E), the term ‘nursing staff’
means a registered professional nurse, a li-
censed practical or licensed vocational nurse, or
a certified nurse aide.
‘‘(3) ANNUAL AUDITS.—
‘‘(A) IN
GENERAL.—The Secretary shall
conduct annual audits of the use of grant funds
made available under paragraph (2). The Sec-
retary shall assess the extent to which such
funds have resulted in increased nursing staff,
reduced nursing staff turnover, increased train-
ing of nursing staff, and improvements in the
quality of care furnished in nursing facilities lo-
cated in States receiving such grant funds.
‘‘(B) ADDITIONAL TERMS FOR RECEIPT OF
GRANT
FUNDS.—As a part of a plan under
paragraph (2)(C), the State shall afford the
Secretary access to any records or information
relating to the plan for the purposes of an audit
of the State’s use of grant funds.
‘‘(C) ANNUAL
REPORT.—The Secretary
shall submit to Congress an annual report on
the audits conducted under this paragraph.’’.
SEC. 4. INCREASED PUBLIC DISCLOSURE OF NURSING
HOME CONDITIONS.
(a) INTERNET DISCLOSURE.—Section 1919(g)(5) of
the Social Security Act (42 U.S.C. 1396r(g)(5)) is amend-
ed by adding at the end the following new subparagraph:
‘‘(E) PUBLICATION ON THE INTERNET OF
NURSING FACILITY INFORMATION.—As soon as
practicable, but in no case later than January
1, 2002, the Secretary shall make available to
the public on the Internet site of the Depart-
ment of Health and Human Services, and by
such other means as the Secretary determines
appropriate, the following information with re-
spect to each nursing facility:
‘‘(i) COMPLIANCE
WITH
FACILITY
STANDARDS.—A summary of the facility’s
compliance or noncompliance with Federal
nursing facility standards.
‘‘(ii) COPIES OF RECENT SURVEYS.—
A copy of the three most recent surveys
conducted of the nursing facility under
subsection (g).
‘‘(iii) COMPLAINTS
FILED
AGAINST
THE FACILITY.—A summary of each com-
plaint filed against the nursing facility
during the three most recent years and a
summary of the outcome or current status
of the complaint.
‘‘(iv) 
ENFORCEMENT
ACTIONS
AGAINST
THE
FACILITY.—A summary of
each enforcement action undertaken by the
Secretary or a State during the three most
recent years with respect to the facility
and a summary of the outcome or current
status of the action.
‘‘(v) NURSE STAFFING RATIOS.—Data
on the nursing staff of the facility for each
of the four previous calendar quarters, in-
cluding the following ratios:
‘‘(I) The ratio of registered pro-
fessional nurses to residents of the fa-
cility.
‘‘(II) The ratio of licensed prac-
tical or licensed vocational nurses to
residents of the facility.
‘‘(III) The ratio of certified nurse
aides to residents of the facility.
‘‘(IV) The ratio of aggregate
nursing staff to residents of the facil-
ity.
Such data shall include information on
such ratios by shift. Such ratios shall be
calculated by comparing the number of
hours such staff expend providing nursing
care to residents of the facility to the num-
ber of residents in the facility.
‘‘(vi) OWNERSHIP DISCLOSURE.—The
identity of the owner and operator of the
nursing facility, including an identification
of whether the facility is a part of a chain
of nursing facilities, and if so, the identity
of the chain and the number of facilities in
such chain.
‘‘(vii) LABOR VIOLATIONS.—Violations
of Federal labor and employment laws, and
costs incurred for activities directly related
to influencing employees with respect to
unionization, during the three most recent
years.
‘‘(viii) OTHER PERTINENT INFORMA-
TION.—Any other information that the
Secretary determines appropriate to inform
the public on conditions and quality of care
furnished at the facility.
shall establish a procedure for the electronic
transmission of such records.
‘‘(B) CERTIFICATION.—A report required
under this paragraph shall be certified by the
administrator of the nursing facility as being
true, accurate, and complete.’’.
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