I
107TH CONGRESS
1ST SESSION
H. R. 1510
To establish a demonstration project to waive certain nurse aide training
requirements for specially trained individuals who perform certain specific
tasks in nursing facilities participating in the medicare or medicaid
programs, and to conditionally authorize the use of resident assistants
in such nursing facilities.
IN THE HOUSE OF REPRESENTATIVES
APRIL 4, 2001
Mr. RYAN of Wisconsin (for himself and Mr. POMEROY) introduced the fol-
lowing bill; which was referred to the Committee on Ways and Means,
and in addition to the Committee on Energy and Commerce, for a period
to be subsequently determined by the Speaker, in each case for consider-
ation of such provisions as fall within the jurisdiction of the committee
concerned
A BILL
To establish a demonstration project to waive certain nurse
aide training requirements for specially trained individ-
uals who perform certain specific tasks in nursing facili-
ties participating in the medicare or medicaid programs,
and to conditionally authorize the use of resident assist-
ants in such nursing facilities.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘Medicare and Medicaid
Nursing Services Quality Improvement Act of 2001’’.
SEC. 2. DEMONSTRATION PROJECT TO WAIVE CERTAIN
NURSE AIDE TRAINING REQUIREMENTS FOR
SPECIALLY TRAINED INDIVIDUALS WHO PER-
FORM CERTAIN COVERED TASKS IN MEDI-
CARE AND MEDICAID NURSING FACILITIES.
(a) DEMONSTRATION PROJECT.—Not later than Oc-
tober 1, 2001, the Secretary shall conduct a demonstra-
tion project under which a resident assistant may perform
a covered task for a resident of a covered nursing facility
in a demonstration State.
(b) REQUIREMENTS.—
(1) MINIMUM
STAFFING
REQUIREMENTS
NOT
AFFECTED.—A resident assistant performing a cov-
ered task under this section—
(A) may augment, but not replace, existing
staff of a covered nursing facility; and
(B) shall not be counted toward meeting or
complying with any requirements for nursing
care staff and functions of such a facility, in-
cluding any minimum nursing staffing require-
ment imposed under section 1819 or 1919 of
the Social Security Act (42 U.S.C. 1395i–3,
1396r).
(2) EXCLUSION OF PARTICIPATION.—
(A) BASED
ON
REPLACEMENT
OF
CER-
TIFIED NURSING STAFF.—
(i) IN
GENERAL.—Subject to clause
(ii), the Secretary may exclude from par-
ticipation in the demonstration project any
covered facility that the Secretary deter-
mines (on the basis of data submitted
under subsection (c) or otherwise) has re-
placed certified nurse assistants with resi-
dent assistants.
(ii) LIMITATION.—The Secretary may
not exclude a facility under clause (i) un-
less the Secretary has reviewed all perti-
nent data that may reflect on a reduction
of nursing staff in the facility, including
changes in resident population and case
mix.
(B) 
BASED
ON
POOR
TREATMENT
RECORDS
OR
INSUFFICIENT
LICENSED
STAFF.—The Secretary may exclude from par-
ticipation in the demonstration project any cov-
ered nursing facility that a State survey agency
recommends be excluded because of unsatisfac-
tory treatment records or insufficient licensed
staff to provide supervision of resident assist-
ants.
(c) DATA COLLECTION.—
(1) DATA REGARDING INITIAL WORKFORCE.—
(A) IN GENERAL.—At the beginning of a
covered nursing facility’s participation in the
demonstration project, the facility shall submit
to the appropriate State agency of the dem-
onstration State independently verifiable data
regarding the composition of the facility’s work-
force at the time such participation commences.
(B) DATA REGARDING RESIDENT ASSIST-
ANTS.—Such data shall include—
(i) the number of resident assistants
in the facility hired solely to perform cov-
ered tasks and the number of such assist-
ants performing additional tasks; and
(ii) the number of residents of the fa-
cility who are served by such resident as-
sistants.
(C) TRANSMITTAL
OF
DATA
TO
SEC-
RETARY.—The State agency shall forward such
data to the Secretary.
(2) DATA REGARDING PERFORMANCE OF RESI-
DENT ASSISTANTS.—Each such facility shall submit
(ii) wage structures in effect for such
certified nursing assistants during the
demonstration project and, in particular,
whether payment under such structures
decreased as a result of the use of resident
assistants; and
(iii) instances of resident assistants
being promoted to certified nurse assistant
positions; and
(D) examine resident satisfaction with re-
spect to nutrition and hydration services pro-
vided by resident assistants.
(4) ADVISORY PANEL.—
(A) DUTIES.—Not later than November 1,
2003, the Secretary shall convene an advisory
panel that shall—
(i) review and evaluate the data col-
lected in accordance with subsection (c);
and
(ii) submit recommendations on the
use or improvement of resident assistants
in covered nursing facilities.
(B) MEMBERSHIP.—The advisory panel
convened under subparagraph (A) shall consist
of representatives of the following:
(i) The Health Care Financing Ad-
ministration of the Department of Health
and Human Services.
(ii) National and local organizations
representing for-profit and nonprofit cov-
ered nursing facilities.
(iii) Consumer groups.
(iv) State long-term care ombudsmen
or other nursing facility resident advocates
of the State.
(v) Labor organizations.
(vi) State survey and licensure agen-
cies.
(vii) Licensed health care providers.
(viii) Dietitians.
(ix) Speech therapists.
(x) Any other entities or individuals
that the Secretary deems appropriate.
(e) AUTHORIZATION OF APPROPRIATIONS.—There is
authorized to be appropriated such sums as may be nec-
essary to carry out this section.
(f) DEFINITIONS.—In this section:
(1) DEMONSTRATION STATE.—The term ‘‘dem-
onstration State’’ means—
(A) Wisconsin,
(B) North Dakota, and
(C) not more than 6 States (other than
Wisconsin and North Dakota) as selected by
the Secretary which, as of the date of enact-
ment of this Act, have established or proposed
a project, program, or policy to permit individ-
uals who do not meet nurse aide training re-
quirements to perform a covered task.
(2) COVERED
NURSING
FACILITY.—The term
‘‘covered nursing facility’’ means—
(A) a skilled nursing facility (as that term
is defined in section 1819(a) of the Social Secu-
rity Act (42 U.S.C. 1395i–3(a))), and
(B) a nursing facility (as that term is de-
fined in section 1919(a) of the Social Security
Act (42 U.S.C. 1396r(a))).
(3) RESIDENT ASSISTANT.—
(A) IN GENERAL.—The term ‘‘resident as-
sistant’’ means an individual who does not meet
nurse aide training requirements (as defined in
paragraph (5)) but who does meet the require-
ments specified in subparagraph (B).
(B) 
RESIDENT
ASSISTANT
REQUIRE-
MENTS.—For purposes of subparagraph (A),
the requirements specified in this subparagraph
are the following:
(i) The individual has successfully
completed an initial training program ad-
ministered by the facility that meets the
requirements of subparagraph (C) and
subsequent competency evaluations, as re-
viewed and approved by the demonstration
State (which, with respect to the training
program, may be during the facility’s
standard survey).
(ii) The individual is performing a
covered task under the onsite supervision
(as defined in paragraph (6)) of a licensed
health professional (as defined in section
1819(b)(5)(G) of the Social Security Act
(42 U.S.C. 1395i–3(b)(5)(G))).
(iii) In the case of an individual per-
forming a feeding and hydration covered
task, the determination of the residents
who may receive such a task from a resi-
dent assistant shall be based on the needs
and potential risks to the resident, as ob-
served and documented in the resident’s
written plan of care and the comprehensive
assessment of the resident’s functional ca-
pacity required under section 1818(b) or
1919(b) of the Social Security Act (42
U.S.C. 1395i–3(b), 1396r(b)).
(iv) The individual complies with any
other limitations on performance of duties
which may be established by the dem-
onstration State.
(C) 
TRAINING
PROGRAM
REQUIRE-
MENTS.—For purposes of subparagraph (B)(i),
a training program shall—
(i) relate to the performance of the
covered task to be performed by the indi-
vidual; and
(ii) include—
(I) feeding skills and assistance
with eating;
(II) the importance of good nu-
trition and hydration, including famil-
iarity with signs of malnutrition and
dehydration;
(III) an overview of the aging
and disease process, as it relates to
nutrition and hydration services;
(IV) how to respond to a choking
emergency and alert licensed staff to
other health emergencies;
(V) universal precautions for the
prevention of the spread of commu-
nicable diseases; and
(VI) a statement of residents’
rights.
(4) COVERED TASK.—
(A) IN
GENERAL.—The term ‘‘covered
task’’ means feeding and hydration.
(B) EXCLUSIONS.—Such term does not
include—
(i) administering medication,
(ii) providing direct medical care, in-
cluding taking vital signs, skin care, or
wound care, or
(iii) performing range of motion or
other therapeutic exercises with residents.
(5) NURSE AIDE TRAINING REQUIREMENTS.—
The term ‘‘nurse aide training requirements’’ means
the requirements of sections 1819(b)(5)(F) and
1919(b)(5)(F) of the Social Security Act (42 U.S.C.
1395i–3(b)(5)(F) and 1396r(b)(5)(F)) relating to
nurse aides.
(6) ONSITE SUPERVISION.—The term ‘‘onsite
supervision’’ means that a licensed health profes-
sional referred to in paragraph (3)(B)(ii) is in the
unit or floor where services are being provided, and
is readily available to provide assistance if necessary.
(7) SECRETARY.—The term ‘‘Secretary’’ means
the Secretary of Health and Human Services.
(8) DEMONSTRATION
PROJECT.—The term
‘‘demonstration project’’ means the demonstration
project conducted under this section.
(9) STATE.—The term ‘‘State’’ has the mean-
ing given such term for purposes of titles XVIII and
XIX of the Social Security Act (42 U.S.C. 1395 et
seq., 1396 et seq.).
SEC. 3. AUTHORIZING THE USE OF RESIDENT ASSISTANTS
IN NURSING FACILITIES RECEIVING PAY-
MENTS UNDER THE MEDICARE OR MEDICAID
PROGRAM.
(a) IN GENERAL.—Subsection (b) of sections 1819
and 1919 (42 U.S.C. 1395i–3, 1396r) of the Social Secu-
rity Act, as amended by section 941 of the Medicare, Med-
icaid, and SCHIP Benefits Improvement and Protection
Act of 2000, as enacted into law by section 1(a)(6) of Pub-
lic Law 106–554, are each amended by adding at the end
the following new paragraph:
‘‘(9) USE OF RESIDENT ASSISTANTS.—
‘‘(A) IN
GENERAL.—Subject to the suc-
ceeding provisions of this paragraph, a skilled
nursing facility may use a resident assistant to
perform a covered task for a resident of the fa-
cility that would otherwise be performed by a
nurse aide.
‘‘(B) DEFINITION.—The term ‘resident as-
sistant’ means an individual—
‘‘(i) who has successfully completed
an initial training program and com-
petency evaluation, and subsequent com-
petency evaluations, approved by the State
under subsection (e)(6); and
‘‘(ii) who is competent to perform a
covered task.
‘‘(C) REQUIREMENT FOR ONSITE SUPER-
VISION.—A resident assistant may only perform
a covered task under the supervision of a li-
censed health professional (as defined in para-
graph (5)(G)) who is present in the unit or
floor where the covered task is performed and
who is readily available to provide assistance to
the resident assistant.
‘‘(D) REQUIREMENT FOR DETERMINATION
OF APPROPRIATE PATIENTS.—A resident assist-
ant may only perform a covered task for a resi-
dent who is approved for such purpose based on
the needs of, and potential risks to, the resi-
dent, as observed and documented in the resi-
dent’s written plan of care and the comprehen-
sive assessment of the resident’s functional ca-
pacity required under this subsection.
‘‘(E) ADDITIONAL
REQUIREMENTS.—The
individual complies with any other limitations
on performance of duties which may be estab-
lished by the State in which the covered task is
performed.
‘‘(F) MINIMUM STAFFING REQUIREMENTS
NOT AFFECTED.—A resident assistant shall not
be counted toward meeting or complying with
any requirement for nursing care staff and
functions of such facilities under this section,
including any minimum nursing staffing re-
quirement.
‘‘(G) COVERED TASK DEFINED.—For pur-
poses of this section, the term ‘covered task’
means feeding and hydration.’’.
(b) SPECIFICATION
OF TRAINING PROGRAM
AND
COMPETENCY EVALUATION STANDARDS.—
(1) REQUIREMENT
FOR
STANDARDS.—Sub-
section (e) of such sections are each amended by
adding at the end the following new paragraph:
‘‘(6) SPECIFICATION AND REVIEW OF RESIDENT
ASSISTANT TRAINING PROGRAMS AND COMPETENCY
EVALUATION
AND
OF
RESIDENT
ASSISTANT
COM-
PETENCY EVALUATIONS.—The State must—
‘‘(A) specify those initial training programs
and competency evaluations, and those subse-
quent competency evaluations, that the State
approves for purposes of subsection (b)(9) and
that meet the requirements established under
subsection (f)(8), and
‘‘(B) provide for the review and reapproval
of such evaluations, at a frequency and using a
methodology consistent with the requirements
established under subsection (f)(8).’’.
(2) 
SPECIFICATION
OF
STANDARDS.—Sub-
section (f) of such sections are each amended by
adding at the end the following new paragraph:
‘‘(8) REQUIREMENTS FOR RESIDENT ASSISTANT
TRAINING
PROGRAMS
AND
COMPETENCY
EVALUA-
TIONS AND FOR RESIDENT ASSISTANT COMPETENCY
EVALUATIONS.—
‘‘(A) IN GENERAL.—For purposes of sub-
sections (b)(9) and (e)(6), the Secretary shall
establish requirements for the approval of resi-
dent assistant training programs and com-
petency evaluations administered by the facility,
including—
‘‘(i) requirements described in sub-
paragraph (B),
‘‘(ii) minimum hours of initial and on-
going training and retraining,
‘‘(iii) qualifications of instructors,
‘‘(iv) procedures for determination of
competency, and
‘‘(v) the minimum frequency and
methodology to be used by a State in re-
viewing compliance with the requirements
for such evaluations.
‘‘(B) REQUIREMENTS
DESCRIBED.—For
purposes of subparagraph (A), the requirements
described in this subparagraph are the fol-
lowing:
‘‘(i) Feeding skills and assistance with
eating.
‘‘(ii) The importance of good nutrition
and hydration, including familiarity with
signs of malnutrition and dehydration.
‘‘(iii) An overview of the aging and
disease process, as it relates to nutrition
and hydration services.
‘‘(iv) How to respond to a choking
emergency and alert licensed staff to other
health emergencies.
‘‘(v) Universal precautions for the
prevention of the spread of communicable
diseases.
‘‘(vi) Residents’ rights.
‘‘(C) SPECIAL
RULE
FOR
STATE
DEM-
ONSTRATION PARTICIPANTS.—In the case of a
State that was a demonstration State (as that
term is defined in subsection (f)(1) of section 2
of the Medicare and Medicaid Nursing Services
Quality Improvement Act of 2001), to the ex-
tent that the demonstration State has in effect
any requirement for the approval of resident as-
sistant training programs and competency eval-
uations that meets or exceeds the same require-
ment that the Secretary establishes under this
paragraph, 
notwithstanding 
subsection
(b)(9)(B)(i) resident assistants who performed
the covered task in facilities in that State under
that demonstration project—
‘‘(i) do not have to complete the entire
initial training program and competency
evaluation required under that subsection;
and
‘‘(ii) shall only be required to meet
those requirements for such approval that
the Secretary establishes under this para-
graph that the State does not have in ef-
fect.’’.
(c) CONTINGENT
EFFECTIVE
DATE.—(1) The
amendments made by this section shall become effective
(if at all) in accordance with paragraph (2).
(2)(A) Not later than December 1, 2004, the Sec-
retary of Health and Human Services (in this paragraph
referred to as the ‘‘Secretary’’) shall submit to Congress
a report on the results of the demonstration project estab-
lished under section 2 that analyzes the effect on resident
care in authorizing the use of resident assistants to fur-
nish feeding and hydration services to residents in skilled
nursing facilities under the medicare program and resi-
dents in nursing facilities under the medicaid program in
the demonstration States.
(B) Such project shall be discontinued, and the
amendments made by this section shall become effective,
on January 1, 2005, unless the Secretary includes in that
report a finding, on the basis of data collected under sec-
tion 2(c) that—
(i) authorizing the use of such resident assist-
ants to furnish such services diminishes the quality
of feeding and hydration services furnished to resi-
dents of those facilities; or
(ii) any decreased recruitment and retention of
nursing staff of those facilities and reduced salaries
for such nursing staff is directly attributable to the
use of such resident assistants to furnish such serv-
ices.
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