I 
108TH CONGRESS 
1ST SESSION H. R. 3355
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 
OCTOBER 21, 2003
Mr. WAXMAN (for himself, Mr. DINGELL, Mr. STARK, Mr. BROWN of Ohio, 
Mr. FROST, Mr. GEORGE MILLER of California, Ms. SCHAKOWSKY, Mr. 
CARSON of Oklahoma, Mr. RODRIGUEZ, Mr. MARKEY, Ms. NORTON, Ms. 
KAPTUR, Mr. SANDERS, Mr. HOEFFEL, Mrs. MALONEY, Mr. GRIJALVA, 
Mr. HINCHEY, Mr. UDALL of New Mexico, Mr. ACEVEDO-VILA´, Mr. 
KUCINICH, Mr. MOORE, Mr. LANTOS, Ms. CORRINE BROWN of Florida, 
Mr. THOMPSON of Mississippi, Mr. BERMAN, Mr. WEXLER, Mr. EVANS, 
Ms. ROYBAL-ALLARD, Mr. KILDEE, Ms. BALDWIN, Mrs. CAPPS, Ms. 
SOLIS, Mr. STUPAK, Mr. KLECZKA, Mr. BACA, Mr. MCGOVERN, Mr. 
HOLT, Mr. PALLONE, Ms. ESHOO, Mr. BRADY of Pennsylvania, Mr. 
CLAY, and Mr. MCDERMOTT) introduced the following bill; which was re-
ferred to the Committee on Energy and Commerce, and in addition to 
the Committee on Ways and Means, for a period to be subsequently de-
termined by the Speaker, in each case for consideration of such provisions 
as fall within the jurisdiction 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 2003’’. 
(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-