Opinion ID: 3049925
Heading Depth: 2
Heading Rank: 1

Heading: Chevron Step One: Unambiguous Meaning

Text: A) Standard We must first determine whether the meaning of the Reform Law is plain and unambiguous and, therefore, controlling. See Maria-Gonzalez, 268 F.3d at 668. To determine if Congress has directly spoken to the issue of whether feeding nursing home residents without complicated feeding problems is a nursing or nursing-related activity, “we employ the traditional tools of statutory construction; if Congress had an intent on this issue, that intent is the law and must be given effect.” Student Loan Fund of Idaho, Inc. v. U.S. Dep’t of Educ., 272 F.3d 1155, 1165 (9th Cir. 2001) (internal quotations omitted). These tools of construction require us first to engage in a textual analysis of the relevant statutory provisions and to read the words of statutes in their context and with a view to their place in the overall statutory scheme. If the proper interpretation is not clear from this textual analysis, the legislative history offers valuable guidance and insight into Congressional intent. However, it is well established that legislative history which does not demonstrate a clear and certain congressional intent cannot form the basis for enjoining regulations. Id. (citations and quotation marks omitted). In conducting this analysis, we may not rewrite a statute, but instead simply “construe what Congress has written. After all, Congress expresses its purpose by words. It is for us to ascertain—neither to add nor to subtract, neither to delete nor to distort.” 62 Cases, More or Less, Each Containing Six Jars of Jam v. United States, 340 U.S. 593, 596 (1951). “[U]nless otherwise defined, words will be interpreted as taking their ordinary, contemporary, common meaning.” Wilderness Soc’y RESIDENT COUNCILS OF WASHINGTON v. LEAVITT 11095 v. U.S. Fish & Wildlife Serv., 353 F.3d 1051, 1060 (9th Cir. 2003) (en banc) (internal quotations omitted). If necessary to discern Congress’s intent, we may look to “the structure and purpose of a statute . . . in determining the plain meaning of its provisions.” Id. If Congress has spoken directly to the question at hand, we may not defer to a contrary agency interpretation. Id. at 1061. B) Analysis Although Plaintiffs acknowledge that the Reform Law neither expressly defines “nursing or nursing-related services,” nor explicitly states that all resident feeding must be performed by a certified nurse aide, they nonetheless contend that the Reform Law’s plain language, general purpose, and structure demonstrate that Congress clearly intended all resident feeding to be performed by certified nurse aides. 1) Plain Language [1] As noted above, the Reform Law prohibits the full-time use of any individual performing “nursing or nursing-related services to residents” for more than four months unless the individual has completed a minimum of 75 hours of training. 42 U.S.C. §§ 1395i-3(b)(5)(A); 1395i-3(b)(5)(F); 1395i- 3(f)(2)(A)(i); 1396r(b)(5)(A); 1396r(b)(5)(F); 1396r(f)(2) (A)(i). Congress provided no further elaboration on its intent or the definitions of the relevant terms in the statutory text or legislative history. See, e.g., H.R. Rep. 100-391(I), at 457, 930. Referencing dictionary definitions of “nursing” and “related,”6 Plaintiffs contend that the statute’s meaning is clear: 6 Citing the Oxford English Dictionary, Second Edition, Plaintiffs define “nursing” as “[t]he practice or profession of providing health care as a nurse” and “related” as “[h]aving relation to, or relationship with, something else.” 11096 RESIDENT COUNCILS OF WASHINGTON v. LEAVITT They argue that the inclusion of “ ‘nursing-related [services]’ indicates that certification is required for the personal care assistance that has a relation to the health care provided to nursing home residents,” and they assert ipse dixit that such assistance “includes assistance with eating, as well as assistance with other activities of daily living such as dressing, walking, and using the toilet.” No support is offered for this claim beyond the statement that “residents live in nursing homes only because they cannot live independently [and] . . . need substantial assistance to perform daily tasks such as dressing, walking, eating, and using the toilet.” True as this might be in most cases, it fails to account for the regulations’ limited application to residents without complicated feeding problems. All agree that feeding the most infirm or medically challenging residents constitutes “nursing-related activity” and requires a nurse aide. The next argument is that the statute’s plain language clearly “demonstrate[s] a decision by Congress to require that all hands-on care by nursing home staff members be provided exclusively by licensed health professionals, registered dieticians, or [certified nurse aides].” Again, little support is offered. Although a congressional committee has noted that “nurse aides provide most of the ‘hands-on’ care to nursing faclity [sic] residents,” H.R. Rep. 101-247, at 459 (1989), reprinted in 1989 U.S.C.C.A.N. 1906, 2185, and the Secretary has described nurse aides as “performing tasks on an individual,” in “direct contact with a resident,” and “directly involved in patient care,” 42 C.F.R. § 483.152(a)(3), (b)(1); 56 Fed. Reg. at 48,890, it simply does not follow that nurse aides must perform all hands-on care of nursing home residents. At most, these statements indicate that all work performed by nurse aides is “hands-on.” They do not, however, support the converse—i.e., that all hands-on work must be performed by nurse aides. [2] In sum, nothing in the statutory language or legislative history clearly shows that Congress intended the phrase RESIDENT COUNCILS OF WASHINGTON v. LEAVITT 11097 “nursing-related services” to include all resident feeding or that all hands-on care be performed by nurse aides. Unable to identify Congress’s clear intent from the plain language, we turn to the purpose and structure of the statute. 2) Purpose and Structure a) Purpose Plaintiffs note that because the Reform Law is remedial in nature it should therefore be construed broadly in light of its purpose. See Tcherepnin v. Knight, 389 U.S. 332, 336 (1967) (noting the “familiar canon of statutory construction that remedial legislation should be construed broadly to effectuate its purposes”). Plaintiffs contend that the Reform Law’s purpose and structure indicates that the phrase “nursing or nursing-related services” “includes virtually all hands-on care provided in a nursing home.” [3] All agree that the “central purpose” of the Reform Law was “to improve the quality of care for Medicaid-eligible nursing home residents.” H.R. Rep. No. 100-391(I) at 452. Plaintiffs argue this purpose was to be served “in large part through the nurse aide certification standards,” which must therefore “apply broadly to all staff members providing hands-on assistance with activities of daily living.” Once again, no support is offered for the assertion that Congress intended “all hands-on care” to be performed by nurse aides. True as it may be that nurse aide certification plays an important part in Congress’s efforts to improve nursing home care via the Reform Law, this says nothing about whether the feeding of residents without complicated feeding problems constitutes a “nursing-related service” that Congress intended to address through nurse aide certification. [4] In sum, as the district court held, congressional intent that resident feeding constitutes a nursing-related service can11098 RESIDENT COUNCILS OF WASHINGTON v. LEAVITT not be gleaned from the Reform Law’s general purpose to improve nursing home care. b) Structure [5] We next address whether the Reform Law’s structure— explicitly delegating specific tasks to the Secretary— demonstrates that Congress did not intend to delegate the task of defining “nursing or nursing-related services.” Plaintiffs note, for example, that the Reform Law specifies that the Secretary should define “serious mental illness” and “specialized services.” See 42 U.S.C. § 1396r(e)(7)(G)(i), (iii). While true that definition of certain terms was expressly left to the Secretary’s discretion, there is nothing to indicate Congress intended to prohibit the Secretary from defining other terms— especially where the terms were otherwise left undefined by the Reform Law. It strains credulity to accept the argument that the Secretary may only define terms when expressly authorized to do so by Congress, given that Congress made no attempt to define the generic, yet vital, phrase “nursing or nursing-related services.” Chevron itself acknowledges the possibility of implicit delegation to the agency where the statute is silent. 467 U.S. at 843-44. Further, the Secretary undeniably has general rulemaking authority, 42 U.S.C. §§ 1302, 1395hh(a)(1), as well as specific rulemaking authority with respect to nursing homes, id. §§ 1395i-3(f), 1396r(f), and we have regularly applied Chevron deference to agency interpretations of the Medicare and Medicaid statutes, see, e.g., Alaska Dep’t of Health & Soc. Servs. v. Ctrs. for Medicare & Medicaid Servs., 424 F.3d 931, 938-39 (9th Cir. 2005). In addition, contrary to Plaintiffs’ contention, the Secretary’s claimed discretion to define “nursing-related services” is not “virtually unchecked.” There are certain activities that so clearly fall within the ambit of “nursing-related services” that the Secretary would not be able to reasonably remove RESIDENT COUNCILS OF WASHINGTON v. LEAVITT 11099 them from the definition by regulation. However, feeding residents without complicated feeding problems does not fit so clearly within the plain meaning of “nursing related”; and it is such borderline activities over which the Secretary has discretion. To hold otherwise, and conclude that the Secretary lacked discretion to define “nursing-related services,” would be to leave a critical statutory term incurably vague, frustrating the purpose and effectiveness of the Reform Law. Plaintiffs’ final argument—that even if the Secretary has discretion to define “nursing or nursing-related services,” Congress did not intend the definition to change based on employment conditions and therefore the current nationwide nurse aide shortage reported by the Secretary cannot justify a changed definition—is also ultimately unpersuasive.7 [6] Although the Secretary’s examination of the definition of “nursing-related services” appears to have been prompted by changed market conditions, the regulations are the result of the Secretary’s subsequent conclusion that feeding residents without complicated feeding problems did not constitute a “nursing-related service”—a determination that was made based on the nature of the activity in question. The nurse aide shortage was relevant only insofar as it prompted the Secretary to reevaluate the regulations in order to ensure the best care possible was being provided to nursing home residents.8 7 Plaintiffs are likely correct that market conditions should not control an agency’s statutory interpretation. See 56 Fed. Reg. at 48884-85 (rejecting a suggestion to allow a waiver of training requirements for facilities unable to attract enough nurse aides). 8 Because the nurse aide shortage was not why the Secretary determined that feeding residents without complicated feeding problems was a nonnursing-related service, Plaintiffs’ argument that the Reform Law expressly provides for waiver of nurse requirements in case of staff shortage, but does not do so for nurse aides, is irrelevant. See 42 U.S.C. § 1395i-3(b)(4)(C)(i)-(ii). The current regulation does not waive nurse aide requirements. Rather, it specifies that certain services previously assumed to be “nursing-related” are not and thus need not be performed by nurse aides. Nursing homes must continue to meet the various nurse aide requirements; the current regulations simply clarify that feeding residents without complicated feeding problems is not a “nursing-related service.” 11100 RESIDENT COUNCILS OF WASHINGTON v. LEAVITT 3) Conclusion Congress did not define the phrase “nursing or nursingrelated service” in either the Reform Law or its legislative history. Neither did it state that all hands-on care (or all feeding tasks) must be performed by nurse aides. Nor can such an intent be derived from the statute’s general purpose or structure. Accordingly, Congress did not speak directly to the question at hand and our analysis must turn to Chevron’s second step to determine whether the Secretary’s interpretation was a permissible construction of the statute.