II 116th CONGRESS 1st Session S. 2521 IN THE SENATE OF THE UNITED STATES September 19, 2019 Mr. Kaine (for himself and Ms. Hassan ) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions A BILL To award grants for the recruitment, retention, and advancement of direct care workers.

1. Short title This Act may be cited as the Direct Creation, Advancement, and Retention of Employment Opportunity Act or the Direct CARE Opportunity Act . 2. Findings Congress finds the following: (1) Millions of older individuals and individuals with disabilities in the United States require assistance with activities of daily living to live independently and participate in their communities to their fullest extent. The Bureau of the Census projects that by 2060 the population of individuals age 65 or older will double from 49,200,000 in 2016 to 94,700,000. According to the Centers for Disease Control and Prevention, 1 in 4 (or 60,000,000) adults in the United States are living with a disability. (2) The assistance of direct care workers allows older individuals and individuals with disabilities to live with dignity and safety, and to exercise their right to live independently in their own homes and communities, in keeping with what is most appropriate for their needs and preferences. Older individuals and individuals with disabilities may also participate in the direct care workforce, further supporting their ability to live independently. (3) According to PHI, direct care workers provide most of the paid, hands-on care for older individuals and individuals with disabilities. (4) According to PHI, 4,500,000 direct care workers provide care across home and community-based settings, nursing facilities, assisted living facilities, group homes, intermediate care facilities, and hospitals to care for the growing population of older individuals and individuals with disabilities. (5) PHI projects that by 2024, 5,200,000 direct care workers will be needed across all care settings to care for the growing population of older individuals and individuals with disabilities. (6) Many direct care workers lack access to a career pathway or advanced training opportunities. This limits their ability to build competency and expertise in their field that, when gained, may lead to an increase in their earning capacity. According to PHI, more than half of home care workers have completed no formal education beyond high school, making high-quality, transferable training essential to success on the job. (7) As of 2015, the median wage for direct care workers is approximately $11 an hour; wages and earnings for home care workers are even lower in rural areas. Because of low wages, variable work hours, and the inability to access workplace-based benefits, 19 percent of home care workers live below the Federal poverty level as compared to 9 percent of the general United States workforce. Nearly half of direct care workers rely on some form of public assistance to support themselves and their families. (8) According to PHI, approximately 9 in 10 direct care workers are women, more than half are women of color, and one quarter of direct care workers are immigrants. (9) The direct care workforce is plagued with high turnover, low job satisfaction, and workforce shortages. These conditions can contribute to reduced quality of care and threaten the availability of supports for older individuals and individuals with disabilities. (10) Because of the nature of the work, direct care workers suffer from disproportionately high rates of injury. In 2016, the injury rate for nursing assistants was 337 per 10,000 as compared to 100 per 10,000 for other occupations. (11) Training has been shown to reduce worker turnover, reduce rates of injury, and lead to increased job satisfaction. (12) The Institute of Medicine found that to ensure that the United States is prepared to meet the health care needs of older individuals during the 21st century, it is essential that the capacity of the direct care workforce be enhanced in both the number of workers available and their ability to meet their own health care and quality of life needs. 3. Definitions In this Act: (1) Apprenticeship program The term apprenticeship program means an apprenticeship program registered under the Act of August 16, 1937 (commonly known as the National Apprenticeship Act ; 50 Stat. 664, chapter 663; 29 U.S.C. 50 et seq.). (2) Direct care worker The term direct care worker has the meaning given the term in section 799B of the Public Health Service Act ( 42 U.S.C. 295p ). (3) Eligible entity The term eligible entity means— (A) a State; (B) a nonprofit organization, a labor organization, or an entity with shared labor-management oversight— (i) with an established record of recruiting or providing training to direct care workers; or (ii) that establishes a training program in consultation with an organization with an established record of providing training to direct care workers; (C) a local board; (D) a nonprofit entity carrying out an apprenticeship program; (E) an Indian tribe or tribal organization; or (F) a consortium of entities listed in subparagraph (A), (B), (C), (D), or (E) that may also include an institution of higher education. (4) Employ; employer The terms employ and employer have the meanings given the terms in section 3 of the Fair Labor Standards Act ( 29 U.S.C. 203 et seq.). (5) Indian tribe; tribal organization The terms Indian tribe and tribal organization have the meanings given such terms in section 4 of the Indian Self-Determination and Education Assistance Act ( 25 U.S.C. 5304 ). (6) Institution of higher education The term institution of higher education has the meaning given the term in section 101 of the Higher Education Act of 1965 ( 20 U.S.C. 1001 ). (7) Secretary The term Secretary means the Secretary of Labor, except as otherwise specified in this Act. (8) State The term State has the meaning given the term in section 3 of the Carl D. Perkins Career and Technical Education Act of 2006 ( 20 U.S.C. 2302 ). (9) Workforce Innovation and Opportunity Act terms The terms career pathway , career planning , in-demand industry sector or occupation , individual with a barrier to employment , individual with a disability , local board , older individual , one-stop center , on-the-job training , recognized postsecondary credential , region , State board , and supportive services have the meanings given such terms in section 3 of the Workforce Innovation and Opportunity Act ( 29 U.S.C. 3102 ). (10) Work-based learning The term work-based learning has the meaning given the term in section 3 of the Carl D. Perkins Career and Technical Education Act of 2006 ( 20 U.S.C. 2302 ). 4. Authority to award grants; duration (a) Authority To award grants Not later than 12 months after the date of enactment of this Act, the Secretary, in consultation with the Secretary of Health and Human Services, shall award grants— (1) to not fewer than 15 eligible entities to develop and carry out projects for purposes of recruiting, retaining, or providing advancement opportunities to direct care workers; and (2) 5 of which shall be awarded for projects that focus on providing such advancement opportunities. (b) Treatment of continuation activities An eligible entity that carries out activities for purposes of recruiting, retaining, or providing advancement opportunities to direct care workers prior to receipt of a grant under this Act may use such grant to continue carrying out such activities, and shall be treated as an eligible entity carrying out a project described in subsection (a)(1). (c) Duration (1) Grant period A grant under this Act shall be for not less than 5 years. (2) Length of project A project assisted with a grant awarded under this Act shall be carried out for not less than 3 years. 5. Project plans; consultation (a) Project plans (1) In general To receive a grant under this Act, an eligible entity shall submit to the Secretary a project plan for each project to be developed and carried out (or for activities to be continued) with the grant at such time and in such manner as the Secretary may determine, and which shall contain the information described in paragraph (2). (2) Contents A project plan submitted by an eligible entity under paragraph (1) shall include a description of each of the following: (A) Current or projected job openings for, or relevant labor market information related to, direct care workers in the State or region to be served by the project, and the geographic scope of the workforce to be served by the project. (B) Specific efforts and strategies that the project will undertake to reduce barriers to recruitment, retention, or advancement of direct care workers, including an assurance that such efforts will include— (i) an assessment of the wages or other compensation or benefits necessary to recruit and retain direct care workers; and (ii) a description of the project’s projected wages and other compensation or benefits for direct care workers at the State or local level, including a comparison of such projected wages to regional and national wages. (C) In the case of a project offering an education and training program, a description of such program (including any curricula, models, and standards used under the program, and any associated recognized postsecondary credentials for which the program provides preparation, as applicable), which shall include an assurance that such program will provide— (i) an apprenticeship program, work-based learning, or on-the-job training opportunities; (ii) supervision or mentoring; and (iii) a progressively increasing, clearly defined schedule of wages to be paid to the direct care worker that— (I) is consistent with skill gains or attainment of a recognized postsecondary credential; and (II) ensures the entry wage is not less than the greater of— (aa) the minimum wage required under section 6(a) of the Fair Labor Standards Act of 1938 ( 29 U.S.C. 206(a) ); or (bb) the applicable wage required by other applicable Federal or State law, or a collective bargaining agreement. (D) If applicable, any other innovative models or processes the eligible entity will implement to support the retention of direct care workers. (E) The supportive services and benefits to be provided to direct care workers to support the retention of employment of direct care workers. (F) How the eligible entity will make use of career planning to support the identification of advancement opportunities and career pathways for direct care workers in the State or region to be served by the project. (G) How the eligible entity will collect and submit to the Secretary workforce data and outcomes of the project. (H) How the project will— (i) provide adequate and safe equipment, and facilities for training and supervision, including a safe work environment free from discrimination; (ii) provide safety training for direct care workers as part of the education and training program described in subparagraph (C), as applicable; and (iii) provide adequate training for mentors and qualified instructors to ensure compliance with clause (i) and, as applicable, clause (ii). (I) How the eligible entity will consult on the implementation of the project, or coordinate the project with, each of the following entities, to the extent that each such entity is not a part of the eligible entity: (i) The State agency responsible for administering the State plan under title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq.) (or waiver of the plan), or the State agency with primary responsibility for providing services and supports for individuals with intellectual disabilities and individuals with developmental disabilities, for the State to be served by the project. (ii) The local board and State board for the State or for each region to be served by the project. (iii) A nonprofit organization with demonstrated experience with respect to direct care workers. (iv) In the case of a project that carries out an education and training program, a nonprofit organization with demonstrated experience in the development or delivery of curricula or coursework. (v) A nonprofit organization that fosters the professional development and collective engagement of direct care workers, including labor organizations. (vi) A nonprofit organization with expertise in identifying and addressing the care needs of older individuals and individuals with disabilities and their caregivers (including area agencies on aging, as defined in section 102 of the Older Americans Act of 1965 ( 42 U.S.C. 3002 ), and centers for independent living, as described in part C of title VII of the Rehabilitation Act of 1973 ( 29 U.S.C. 796f et seq.). (vii) A nonprofit State provider association that represents providers who employ direct care workers, where such associations exist. (viii) An entity that employs direct care workers. (J) An assurance that any benefit or service provided under the project will be provided at no cost to a direct care worker or individuals assisted by such workers. (K) How the eligible entity will consult with individuals employed as direct care workers, representatives of such workers, individuals assisted by such workers, and the families of such individuals throughout the project. (L) Outreach efforts to individuals for participation in such project, including targeted outreach efforts to— (i) individuals who are recipients of assistance under a State program funded under part A of title IV of the Social Security Act ( 42 U.S.C. 601 et seq.) or individuals who are eligible for such assistance; and (ii) individuals with barriers to employment. (3) Considerations In selecting eligible entities to receive a grant under this Act, the Secretary shall— (A) ensure— (i) equitable geographic and demographic diversity, including rural and urban areas; and (ii) that selected eligible entities will serve areas where direct care, or a related occupation, is an in-demand industry sector or occupation; and (B) give priority to eligible entities proposing to predominantly serve the individuals described in clauses (i) and (ii) of paragraph (2)(L). (b) Consultation The Secretary shall encourage each eligible entity receiving a grant under this Act, in developing and carrying out a project, to consult with— (1) institutions of higher education; (2) the State Apprenticeship Agency recognized under the Act of August 16, 1937 (commonly known as the National Apprenticeship Act ; 50 Stat. 664, chapter 663; 29 U.S.C. 50 et seq.), for the State or region to be served by the eligible entity or, if no such agency has been recognized in the State or region, the Office of Apprenticeship of the Department of Labor; and (3) one-stop centers. 6. Uses of funds; supplement, not supplant (a) Uses of funds (1) In general Each eligible entity receiving a grant under this Act shall use such funds to carry out at least 1 project or to continue activities commenced prior to receipt of such grant that— (A) develop and implement a strategy for the recruitment, retention, or advancement of direct care workers, which includes the activities described in section 5(a)(2); and (B) provide compensation to each eligible direct care worker for any training received under the project or activities. (2) Administrative costs Each eligible entity receiving a grant under this Act shall not use more than 5 percent of the funds of such grant for costs associated with the administration of activities under this Act. (3) Direct support Each eligible entity receiving a grant under this Act shall use not less than 5 percent of the funds of such grant to provide direct financial assistance, such as supportive services, to direct care workers to support the financial needs of such workers to enter, remain enrolled in, and complete the project (or activities) assisted with such grant. (b) Supplement, not supplant An eligible entity receiving a grant under this Act shall use such grant only to supplement, and not supplant, the amount of funds that, in the absence of such grant, would be available to address the recruitment, retention, or advancement of direct care workers in the State or region served by the eligible entity. 7. Evaluations and reports (a) Reports (1) Eligible entities (A) In general Each eligible entity receiving a grant under this Act shall submit to the Secretary and the Secretary of Health and Human Services, with respect to each project assisted with such grant— (i) for each year of the grant period, an annual report on the progress and outcomes of the project; and (ii) not later 6 months after the completion of such project, a final report on the progress and outcomes of the project. (B) Disaggregation Each report submitted under paragraph (A) shall— (i) include the information described in subparagraph (C); and (ii) disaggregate such information in the manner described in subparagraph (D). (C) Contents Each report submitted under subparagraph (A) shall include each of the following: (i) The number of individuals served by the project, including— (I) the number of individuals recruited to be employed as a direct care worker; and (II) the number of individuals who attained employment as a direct care worker. (ii) The number of individuals or families assisted by direct care workers. (iii) The number of direct care workers who participated in and completed— (I) work-based learning; (II) on-the-job training; (III) an apprenticeship program; or (IV) a professional development or mentoring program. (iv) Other services, benefits, or supports (other than the services, benefits, or supports described in clause (iii)) provided to assist in the recruitment, retention, or advancement of direct care workers, the number of individuals who accessed such services, benefits, or supports, and the impact of such services, benefits, or supports. (v) How the project assessed satisfaction with respect to— (I) direct care workers assisted by the project; (II) individuals receiving services delivered by such workers, including any impact on the health or health outcomes of such individuals; and (III) employers of such workers, as determined in accordance with section 116(b)(2)(A)(i)(VI) of the Workforce Innovation and Opportunity Act ( 29 U.S.C. 3141(b)(2)(A)(i)(VI) ). (vi) The performance of the eligible entity with respect to the indicators of performance on unsubsidized employment, median earnings, credential attainment, measurable skill gains, and employer satisfaction, as described under section 116(b)(2)(A)(i) of the Workforce Innovation and Opportunity Act ( 29 U.S.C. 3141(b)(2)(A)(i) ). (vii) Any other information with respect to outcomes of the project. (D) Disaggregation The information described under subparagraph (C) shall be disaggregated by race, ethnicity, sex, and age in accordance with section 116(d)(2)(B) of the Workforce Innovation and Opportunity Act ( 29 U.S.C. 3141(d)(2) ), by each population listed in section 3(24) of the Workforce Innovation and Opportunity Act ( 29 U.S.C. 3102(24) ), and by the individuals described in clauses (i) and (ii) of section 5(a)(2)(L). (2) Secretaries (A) Annual performance review The Secretary, in consultation with the Secretary of Health and Human Services, shall annually conduct a performance review of each project carried out by an eligible entity receiving a grant under this Act, including— (i) the performance of the project with respect to the indicators of performance described in paragraph (1)(C)(vi), and disaggregated in the manner described in paragraph (1)(D); and (ii) the efficacy of the project plan submitted under section 5(a)— (I) for recruiting, retaining, or providing advancement opportunities for direct care workers; and (II) on the methods used to recruit, retain, or provide advancement opportunities to direct care workers. (B) Report to Congress Not later than 1 year after the completion of each project assisted with a grant under this Act, the Secretary, in consultation with the Secretary of Health and Human Services, shall prepare and submit to Congress, and make publicly available, a report containing— (i) the progress and outcomes of the project as identified in the final report submitted by the eligible entity under paragraph (1)(A)(ii); (ii) an analysis of the workforce supply, current and projected shortages, and distribution of direct care workers at the national, regional, and State levels; and (iii) recommendations for such legislative or administrative action, as the Secretary determines appropriate. (3) GAO report Not later than 1 year after the completion of each project assisted with a grant under this Act, the Comptroller General of the United States shall conduct a study and submit to Congress a report including— (A) an assessment of how the project assisted in the recruitment, retention, or advancement of direct care workers; and (B) recommendations for such legislative or administrative actions, as the Comptroller General determines appropriate. (b) Technical assistance Not later than 15 months after the date of enactment of this Act, the Secretary shall provide technical assistance to eligible entities receiving a grant under this Act, for purposes of compliance with subsection (a)(1) of this section, on— (1) the disaggregation requirements of section 116(d)(2)(B) of the Workforce Innovation and Opportunity Act ( 29 U.S.C. 3141(d)(2) ); and (2) the data collection requirements of section 116(b)(2)(A)(i) of such Act ( 29 U.S.C. 3141(b)(2)(A)(i) ). 8. Authorization of appropriations There are authorized to be appropriated such sums as may be necessary to carry out this Act for each of fiscal years 2021 through 2025.