I
106TH CONGRESS
2D SESSION
H. R. 4614
To amend title XVIII of the Social Security Act to require skilled nursing
facilities furnishing services to Medicare beneficiaries to submit data
to the Secretary of Health and Human Services with respect to nursing
staff levels of the facility, to require posting of staffing information
by facilities and the Secretary, to assess the adequacy of training require-
ments for certified nurse aides, and provide for grants to improve the
quality of care furnished in nursing facilities.
IN THE HOUSE OF REPRESENTATIVES
JUNE 8, 2000
Mr. STARK (for himself, Ms. ESHOO, Mr. GEORGE MILLER of California, Ms.
WOOLSEY, Ms. PELOSI, Ms. LEE, and Mr. LANTOS) introduced the fol-
lowing bill; which was referred to the Committee on Ways and Means,
and in addition to the Committee on Commerce, 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 title XVIII of the Social Security Act to require
skilled nursing facilities furnishing services to Medicare
beneficiaries to submit data to the Secretary of Health
and Human Services with respect to nursing staff levels
of the facility, to require posting of staffing information
by facilities and the Secretary, to assess the adequacy
of training requirements for certified nurse aides, and
provide for grants to improve the quality of care fur-
nished in 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; TABLE OF CONTENTS.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Nursing Staff Accountability and Training Improvement
Act of 2000’’.
(b) TABLE OF CONTENTS.—The table of contents of
this Act is as follows:
Sec. 1. Short title.
TITLE I—INFORMATION ON NURSING STAFF IN NURSING
FACILITIES
Sec. 101. Submission of nursing staff level data to the secretary.
Sec. 102. Information on nursing facility staffing.
Sec. 103. Direct spending for administrative expenses of State agencies deter-
mining compliance by providers of services with conditions of
participation.
Sec. 104. Comprehensive report on certified nurse aide training.
Sec. 105. Effective date.
TITLE II—GRANTS TO IMPROVE QUALITY OF NURSING HOME
AND LONG-TERM CARE
Sec. 201. Improvement of training of long-term care professionals and workers.
Sec. 202. Upward mobility of long-term care workers.
Sec. 203. Retention of long-term care professionals and workers in medically
underserved areas.
Sec. 204. Improvement in worker safety.
Sec. 205. Demonstration program to implement quality improvement models in
nursing facility settings.
TITLE 
I—INFORMATION 
ON
NURSING STAFF IN NURSING
FACILITIES
SEC. 101. SUBMISSION OF NURSING STAFF LEVEL DATA TO
THE SECRETARY.
(a) MEDICARE.—
(1) IN GENERAL.—Section 1819(b) of the So-
cial Security Act (42 U.S.C. 1395i–3(b)) is amended
by adding at the end the following new paragraph:
‘‘(8) SUBMISSION OF DATA ON STAFFING LEV-
ELS.—
‘‘(A) IN GENERAL.—A skilled nursing fa-
cility shall submit to the Secretary, in a form
and manner determined by the Secretary, such
data for a covered period (as defined in sub-
paragraph (C)) with respect to nursing staff as
is necessary for the Secretary to determine
whether a resident of the skilled nursing facility
receives the level of care commensurate with the
assessment of the resident under this sub-
section. Such data shall include the total num-
ber of nursing staff hours furnished during
each covered 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 practical or vocational
nurse hours, and total registered nurse hours.
‘‘(B) ADJUSTMENT IN PAYMENT AMOUNT
FOR
INADEQUATE
STAFFING.—If the nursing
staff data discloses that the aggregate nursing
staff hours furnished during the covered period
by the facility for residents for which payment
is made under section 1888(e) during the pe-
riod is less than the aggregate amount cor-
responding to the nursing staff hours which is
the basis of the case mix reimbursement (under
section 1888(e)(4)(G)(i)) for such residents for
the facility for that period, the Secretary shall
make proportionate adjustments in the payment
amounts determined under section 1888(e) to
the facility.
‘‘(C) COVERED PERIOD DEFINED.—
‘‘(i) IN
GENERAL.—For purposes of
this paragraph, the term ‘covered period’
means the lesser of 32 days or the facility
billing period described in clause (ii).
‘‘(ii) FACILITY BILLING PERIOD DE-
SCRIBED.—A facility billing period referred
to in clause (i) the aggregate number of
days between periods that the Secretary
makes payment for claims for services fur-
nished by the facility under this title.’’.
(2) INCLUSION OF NURSING STAFFING LEVELS
IN ANNUAL SURVEY.—Section 1819(g)(2)(A)(ii) of
such Act (42 U.S.C. 1395i–3(g)(2)(A)(ii)) is
amended—
nursing staff of the facility and to determine wheth-
er payments made for such care are appropriate.’’.
(b) MEDICAID.—
(1) ANALYSIS OF SPENDING FOR PATIENT CARE
IN AUDITS OF NURSING FACILITY COST REPORTS.—
(A) IN GENERAL.—A State shall carry out
periodic audits of cost reports submitted by a
nursing facility (as defined in section 1919(a)
of 
the 
Social 
Security 
Act 
(42 
U.S.C.
1396r(a))) operating in the State. Such audits
shall (i) determine the aggregate expenditures
made by the nursing facility during the cost re-
porting period on direct patient care furnished
by licensed health professionals (as defined in
subparagraph (G) of section 1919(b)(5) of such
Act (42 U.S.C. 1396r(b)(5))) and by nurse
aides (as defined in subparagraph (F) of such
section) and (ii) compare such aggregate ex-
penditures to payments made by the State for
such direct patient care.
(B) STUDY.—The Secretary of Health and
Human Services shall conduct a study to deter-
mine the feasibility of developing and admin-
istering a standardized, uniform cost reporting
form for all nursing facilities furnishing services
for which payment is made under title XIX of
the Social Security Act. Any such form should
enable the Secretary to assess the amount of di-
rect patient care referred to in subparagraph
(A) furnished by each nursing facility and to
determine whether payments made for such di-
rect patient care are appropriate.
(2) INCLUSION OF NURSING STAFFING LEVELS
IN ANNUAL SURVEY.—Section 1919(g)(2)(A)(ii) of
the 
Social 
Security 
Act 
(42 
U.S.C.
1396r(g)(2)(A)(ii)) is amended—
(A) by striking ‘‘and’’ at the end of sub-
clause (II);
(B) by striking the period at the end of
subclause (III) and inserting ‘‘; and’’; and
(C) by adding at the end the following new
subclause:
‘‘(IV) a review of the sufficiency
and distribution of staffing in the
skilled nursing facility to meet the
needs of residents 24 hours a day, 7
days a week.’’.
SEC. 102. INFORMATION ON NURSING FACILITY STAFFING.
(a) MEDICARE AMENDMENTS.—
(1) IN GENERAL.—Section 1819(b) of the So-
cial Security Act (42 U.S.C. 1395i–3(b)), as amend-
ed by section 2(a), is further 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 and the cur-
rent ratios of residents to staff, stated sepa-
rately for the ratio of the number of residents
to such licensed nursing staff and the ratio of
the number of residents to such unlicensed
nursing staff. The information shall be dis-
played in a uniform manner and in a clearly
visible place. The facility shall also post in a
clearly visible place annual average daily staff-
ing ratios per shift for the last cost reporting
period.
‘‘(B) PUBLICATION OF DATA.—
‘‘(i) IN GENERAL.—A skilled nursing
facility shall, upon request, make available
to the public nursing staff data to the
same extent and in the same manner as
cost reporting information.
‘‘(ii) INTERNET.—Not later than 60
days after the date of completion of an an-
nual survey under subsection (g)(2), the
Secretary shall provide for the publication
on the Internet Site of the Department of
Health and Human Services known as
Nursing Home Compare the facility-spe-
cific nursing staff information collected
under such survey. The Secretary shall up-
date such information periodically.’’.
(2) PENALTY FOR FAILURE TO POST REQUIRED
INFORMATION.—Section 1819(h)(2) of such Act (42
U.S.C. 1395i–3(h)(2)), is amended by adding at the
end the following new subparagraph:
‘‘(F) MANDATORY CIVIL MONEY PENALTY
FOR
FAILURE
TO
POST
REQUIRED
INFORMA-
TION.—Notwithstanding any other provision of
law, the Secretary shall impose a civil monetary
penalty upon a skilled nursing facility that fails
to meet the posting requirement of subsection
(b)(9). The penalty shall be in the amount of
$1,000 for each day upon which the facility
fails to meet fully such requirement. The provi-
sions of section 1128A of the Social Security
Act (other than subsections (a) and (b)) shall
apply to civil money penalties under this sub-
paragraph in the same manner as they apply to
a penalty or proceeding under section 1128A(a)
of such Act.’’.
(b) MEDICAID AMENDMENTS.—
(1) IN GENERAL.—Section 1919(b) of the So-
cial Security Act (42 U.S.C. 1396r(b)) is amended
by adding at the end the following new paragraph:
‘‘(8) 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 and the cur-
rent ratios of residents to staff, stated sepa-
rately for the ratio of the number of residents
to such licensed nursing staff and the ratio of
the number of residents to such unlicensed
nursing staff. The information shall be dis-
played in a uniform manner and in a clearly
visible place. The facility shall also post in a
clearly visible place annual average daily staff-
ing ratios per shift for the last cost reporting
period.
‘‘(B) PUBLICATION OF DATA.—
‘‘(i) IN GENERAL.—A skilled nursing
facility shall, upon request, make available
to the public nursing staff data to the
same extent and in the same manner as
cost reporting information.
‘‘(ii) INTERNET.—Not later than 60
days after the date of completion of an an-
nual survey under subsection (g)(2), the
Secretary shall provide for the publication
on the Internet Site of the Department of
Health and Human Services known as
Nursing Home Compare the facility-spe-
cific nursing staff information collected
under such survey. The Secretary shall up-
date such information periodically.’’.
(2) Section 1919(h)(3) of such Act (42 U.S.C.
1396r(h)(3)), is amended by adding at the end the
following new subparagraph:
‘‘(E) MANDATORY CIVIL MONEY PENALTY
FOR
FAILURE
TO
POST
REQUIRED
INFORMA-
TION.—Notwithstanding any other provision of
law, the Secretary shall impose a civil monetary
penalty upon a nursing facility that fails to
meet the posting requirement of subsection
(b)(9). The penalty shall be in the amount of
$1,000 for each day upon which the facility
fails to meet fully such requirement. The provi-
sions of section 1128A of the Social Security
Act (other than subsections (a) and (b)) shall
apply to civil money penalties under this sub-
paragraph in the same manner as they apply to
a penalty or proceeding under section 1128A(a)
of such Act. This subparagraph shall not apply
to a failure for which a civil money penalty is
imposed under section 1819(h)(2)(F).’’.
SEC. 103. DIRECT SPENDING FOR ADMINISTRATIVE EX-
PENSES OF STATE AGENCIES DETERMINING
COMPLIANCE BY PROVIDERS OF SERVICES
WITH CONDITIONS OF PARTICIPATION.
(a) IN GENERAL.—Section 1864 of the Social Secu-
rity Act (42 U.S.C. 1395aa) is amended by adding at the
end the following new subsection:
‘‘(f) APPROPRIATION OF CERTAIN FUNDS TO ADMIN-
ISTER THIS SECTION.—The Secretary shall pay expenses
incurred in the administration of this section from funds
in the Federal Hospital Insurance Trust Fund (estab-
lished under section 1817) and the Federal Supple-
mentary Medical Insurance Trust Fund (established
under section 1841), in such amounts from each of such
trust funds as the Secretary shall deem to be fair and eq-
uitable after taking into consideration the expenses attrib-
utable to the administration of this section with respect
to items and services furnished under this title attrib-
utable to parts A and B and under title XI with respect
to those parts, without regard to amounts appropriated
in advance in appropriations Acts, in the same manner
as payments are made for services furnished directly to
individuals entitled to benefits under this title. The Sec-
retary shall make such transfers of monies between such
trust funds as may be appropriate to settle accounts be-
tween them in cases where expenses properly payable from
one such trust fund have been paid from the other trust
fund.’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall take effect October 1, 2000.
SEC. 104. COMPREHENSIVE REPORT ON CERTIFIED NURSE
AIDE TRAINING.
Not later than 18 months after the date of the enact-
ment of this Act, the Secretary of Health and Human
Services shall submit to Congress a comprehensive report
on training of certified nurse aides, and shall include in
that comprehensive report recommendations for the fol-
lowing:
(1) Whether training standards in effect on the
date of the enactment of this Act for certified nurse
aides should be increased from 75 hours (the Fed-
eral minimum number of hours of training for cer-
tification) to 160 hours, or some other minimum
standard.
(2) Whether Federal curriculum standards
should require more focus on each of the following:
(A) The recognition of the symptoms of
malnutrition, dehydration, pain, confusion, and
anxiety.
(B) The prevention and treatment of infec-
tions, bed sores, incontinence, and lack of mo-
bility.
(C) Appropriate strategies for preventing
physical and mental abuse of residents of nurs-
ing facilities, such as conflict resolution and
stress management.
(D) Appropriate care for residents diag-
nosed with dementia or dementia-related dis-
ease.
(E) Care for residents with diminished vis-
ual or audio acuity.
SEC. 105. EFFECTIVE DATE.
The amendments made by sections 101 and 102 take
effect on the first day of the first month that begins at
least 6 months after the date of the enactment of this Act.
TITLE II—GRANTS TO IMPROVE
QUALITY OF NURSING HOME
AND LONG-TERM CARE
SEC. 201. IMPROVEMENT OF TRAINING OF LONG-TERM
CARE PROFESSIONALS AND WORKERS.
(a) GRANT PROGRAM.—
(1) ESTABLISHMENT OF TRAINING CENTERS.—
The Secretary shall, in accordance with the provi-
sions of this section, award grants to a qualified en-
tity to establish education and training programs for
individuals who furnish direct resident care services
in nursing facilities, including registered professional
nurses, licensed practical nurses, and certified nurse
aides.
(2) DISCRETION TO AWARD GRANTS TO EXIST-
ING
TRAINING
PROGRAMS.—The Secretary may
award grants to fund programs of such education
and training carried out by the following:
(A) A qualified entity.
(B) An accredited educational institution.
(C) An institutional health care provider,
including a nursing facility.
(3) PRIORITY OF GRANT AWARDS.—In award-
ing grants under this section, the Secretary shall
give priority to nursing facilities with approved ap-
plications filed in partnership with labor representa-
tives.
(4) DEADLINE FOR INITIAL GRANT AWARDS.—
The Secretary shall award grants under this section
by not later than 6 months after the date of the en-
actment of this Act.
(b) APPLICATIONS.—
(1) APPLICATIONS REQUIRED.—Each qualified
or other entity referred to in subsection (a) that
wishes to receive a grant under this section shall
submit an application at such time, in such form,
and complete with such information as the Secretary
shall by regulation require, except that any such ap-
plication shall include at least—
(A) a statement of the objectives for which
the grant is sought; and
(B) a description of the types of programs
and activities for which the grant is sought.
(2) NOTICE OF APPROVAL OR DISAPPROVAL.—
Each qualified or other entity referred to in sub-
section (a) submitting an application under para-
graph (1) shall, not later than 60 days after the
date of its submission, be notified in writing as to
whether such application is approved or disapproved.
(3) REQUIREMENT OF PRIOR APPROVAL FROM
COLLECTIVE BARGAINING AGENCY.—In the case of a
nursing facility applying for a grant under this sec-
tion that has a collective bargaining agent, the appli-
cation filed by the facility shall include written ap-
proval from that agent for the facility’s proposed use
of the grant award.
(c) DURATION.—A grant under this section may ex-
tend over a period of not more than three years.
(d) ANNUAL APPROVAL.—The provision of payments
under a grant under this section shall be subject to annual
approval by the Secretary and subject to the availability
of appropriations for each fiscal year to make the pay-
ments.
(e) USE OF GRANT FUNDS.—
(1) AUTHORIZED USES.—A grant made under
this section may be used only to carry out to estab-
lish or fund education and training centers for indi-
viduals who furnish direct resident care services in
nursing facilities. Each qualified or other entity re-
ferred to in subsection (a) awarded a grant under
this section shall develop curricula and interdiscipli-
nary programs to enhance direct care workers’ abili-
ties to provide quality care, including for the fol-
lowing:
(A) New training that focuses on—
(i) recognizing signs of malnutrition,
dehydration, pain, confusion, and anxiety,
(ii) prevention and treatment of infec-
tions, bed sores, incontinence, and lack of
mobility,
(iii) strategies for preventing abuse of
residents of nursing facilities, such as con-
flict resolution and stress management,
and
(iv) recognizing symptoms in residents
of nursing facilities of dementia or demen-
tia-related disease.
(B) Continuing education for licensed pro-
viders in the care of the chronically ill and dis-
abled or gerontological nursing, or both.
(2) PROHIBITED USES.—A grant may not be
used to pay for the minimum number of training
hours required for certified nurse aide certification.
(f) REPORTS.—A qualified or other entity referred to
in subsection (a) awarded a grant under this section shall
submit to the Secretary such reports, and within such time
frames, as the Secretary may require.
(g) REGULATIONS.—Any regulations to carry out this
section shall be prescribed not later than 60 days after
the date of enactment of this section.
(h) AUTHORIZATION OF APPROPRIATIONS.—For pur-
poses of carrying out this section, there are authorized to
be appropriated to the Secretary $25,000,000 for each of
fiscal years 2001, 2002, and 2003. 60 percent of such ap-
propriation shall be payable from the Federal Hospital In-
surance Trust Fund, and 40 percent of such appropriation
shall be payable from the Federal Supplementary Medical
Insurance Trust Fund under title XVIII of the Social Se-
curity Act (42 U.S.C. 1395i, 1395t).
(i) DEFINITIONS.—In this section:
(1) The term ‘‘Secretary’’ means the Secretary
of Health and Human Services.
(2) The term ‘‘qualified entity’’ means—
(A) a nursing facility as defined in section
1919(a) of the Social Security Act (42 U.S.C.
1396r(a));
(B) a skilled nursing facility (as defined in
section 1819(a) of such Act (42 U.S.C. 1395i–
3(a));
(C) a labor union;
(D) a community-based nonprofit organiza-
tion;
(E) a State long-term care Ombudsman;
community-based citizen advocacy groups;
(F) a State deparment on aging; and
(G) such other entities approved by the
Secretary.
SEC. 202. UPWARD MOBILITY OF LONG-TERM CARE WORK-
ERS.
(a) GRANT PROGRAM.—
(1) IN GENERAL.—The Secretary shall, in ac-
cordance with the provisions of this section, award
grants to qualified entities to provide for such addi-
tional or advanced education and training of cer-
tified nursing aides who furnish services in the facil-
ity. Such education and training shall be designed to
enable such staff to provide care in accordance with
the limitations of State nurse practice laws or regu-
lations and with principles of nurse delegations.
(2) PRIORITY OF GRANT AWARDS.—In award-
ing grants under this section, the Secretary shall
give priority to nursing facilities with approved ap-
plications filed in partnership with labor representa-
tives.
(3) DEADLINE FOR INITIAL GRANT AWARDS.—
The Secretary shall award grants under this section
by not later than 6 months after the date of the en-
actment of this Act.
(b) APPLICATIONS.—
(1) APPLICATIONS REQUIRED.—Each qualified
entity that wishes to receive a grant under this sec-
tion shall submit an application at such time, in
such form, and complete with such information as
the Secretary shall by regulation require, except that
any such application shall include at least—
(A) a statement of the objectives for which
the grant is sought; and
(B) a description of the types of programs
and activities for which the grant is sought.
(2) NOTICE OF APPROVAL OR DISAPPROVAL.—
Each qualified entity submitting an application
under paragraph (1) shall, not later than 60 days
after the date of its submission, be notified in writ-
ing as to whether such application is approved or
disapproved.
(3) REQUIREMENT OF PRIOR APPROVAL FROM
COLLECTIVE BARGAINING AGENCY.—In the case of a
nursing facility applying for a grant under this sec-
tion that has a collective bargaining agent, the appli-
cation filed by the facility shall include written ap-
proval from that agent for the facility’s proposed use
of the grant award.
(c) DURATION.—A grant under this section may ex-
tend over a period of not more than three years.
(d) ANNUAL APPROVAL.—The provision of payments
under a grant under this section shall be subject to annual
approval by the Secretary and subject to the availability
of appropriations for each fiscal year to make the pay-
ments.
(e) USE OF GRANT FUNDS.—A grant made under
this section may be used only to carry out to establish
education and training programs referred to in subsection
(a)(1).
(f) REPORTS.—A qualified entity awarded a grant
under this section shall submit to the Secretary such re-
ports, and within such time frames, as the Secretary may
require.
(g) REGULATIONS.—Any regulations to carry out this
section shall be prescribed not later than 60 days after
the date of enactment of this section.
(h) AUTHORIZATION OF APPROPRIATIONS.—For pur-
poses of carrying out this section, there are authorized to
be appropriated to the Secretary $25,000,000 for each of
fiscal years 2001, 2002, and 2003. 60 percent of such ap-
propriation shall be payable from the Federal Hospital In-
surance Trust Fund, and 40 percent of such appropriation
shall be payable from the Federal Supplementary Medical
Insurance Trust Fund under title XVIII of the Social Se-
curity Act (42 U.S.C. 1395i, 1395t).
(i) DEFINITIONS.—In this section:
(1) The term ‘‘Secretary’’ means the Secretary
of Health and Human Services.
(2) The term ‘‘qualified entity’’ means—
(A) a nursing facility as defined in section
1919(a) of the Social Security Act (42 U.S.C.
1396r(a));
(B) a skilled nursing facility (as defined in
section 1819(a) of such Act (42 U.S.C. 1395i–
3(a));
(C) a labor union;
(D) a community-based nonprofit organiza-
tion;
(E) a State long-term care Ombudsman;
community-based citizen advocacy groups;
(F) a State deparment on aging; and
(G) such other entities approved by the
Secretary.
SEC. 203. RETENTION OF LONG-TERM CARE PROFES-
SIONALS AND WORKERS IN MEDICALLY UN-
DERSERVED AREAS.
(a) GRANT PROGRAM.—
(1) IN GENERAL.—The Secretary shall, in ac-
cordance with the provisions of this section, award
grants to nursing facilities to establish programs to
retain individuals who furnish direct resident care
services in nursing facilities located in medically un-
derserved areas, including registered professional
nurses, licensed practical nurses, and certified nurse
aides.
(2) DEADLINE FOR INITIAL GRANT AWARDS.—
The Secretary shall award grants under this section
by not later than 6 months after the date of the en-
actment of this Act.
(b) APPLICATIONS.—
(1) APPLICATIONS
REQUIRED.—Each nursing
facility that wishes to receive a grant under this sec-
tion shall submit an application at such time, in
such form, and complete with such information as
the Secretary shall by regulation require, except that
any such application shall include at least—
(A) a statement of the objectives for which
the grant is sought; and