[Congressional Bills 106th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5166 Introduced in House (IH)]







106th CONGRESS
  2d Session
                                H. R. 5166

  To amend titles XVIII and XIX of the Social Security Act to impose 
 requirements with respect to staffing in nursing facilities receiving 
                     Medicare or Medicaid funding.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           September 13, 2000

 Ms. Schakowsky (for herself, Mr. Rush, Mr. Blagojevich, Mrs. McCarthy 
of New York, Mr. Waxman, and Mr. Frost) introduced the following bill; 
which was referred to the Committee on Ways and Means, and in addition 
     to the Committee on Commerce, for a period to be subsequently 
   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 titles XVIII and XIX of the Social Security Act to impose 
 requirements with respect to staffing in nursing facilities receiving 
                     Medicare or Medicaid funding.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Quality Care for Nursing Home 
Patients Act of 2000''.

SEC. 2. STAFFING REQUIREMENTS FOR MEDICARE- AND MEDICAID-FUNDED NURSING 
              FACILITIES.

    (a) Medicare-Funded Skilled Nursing Facilities.--
            (1) Minimum standards.--Section 1819(b)(4) of the Social 
        Security Act (42 U.S.C. 1395i-3(b)(4)) is amended by adding at 
        the end the following new subparagraph:
                    ``(D) Minimum direct care staffing requirements.--
                            ``(i) Licensed nurses.--Subject to 
                        subsection (f)(8), a skilled nursing facility 
                        must have at least one licensed nurse on duty 
                        on the premises for every--
                                    ``(I) 15 residents present during 
                                the day;
                                    ``(II) 20 residents present during 
                                the evening; and
                                    ``(III) 30 residents present during 
                                the night.
                            ``(ii) Direct caregivers.--Subject to 
                        subsection (f)(8), a skilled nursing facility 
                        must have at least one direct caregiver on duty 
                        on the premises for every--
                                    ``(I) 5 residents present during 
                                the day;
                                    ``(II) 10 residents present during 
                                the evening; and
                                    ``(III) 15 residents present during 
                                the night.
                            ``(iii) Counting.--In determining 
                        compliance with the staffing levels under this 
                        subparagraph:
                                    ``(I) Administrative services.--In 
                                a facility with 60 or more beds, an 
                                individual may not be counted while 
                                performing noncaregiving administrative 
                                services.
                                    ``(II) Other services.--An 
                                individual may not be counted while 
                                performing food preparation, 
                                housekeeping, laundry, maintenance 
                                services, or other noncaregiving-
                                related activities.
                            ``(iv) Construction.--The staffing 
                        requirements of this subparagraph are in 
                        addition to the requirements of subparagraph 
                        (C).
                            ``(v) Definitions.--In this subparagraph:
                                    ``(I) Licensed nurse.--The term 
                                `licensed nurse' means a registered 
                                professional nurse, licensed practical 
                                nurse, or licensed vocational nurse who 
                                meets State licensing requirements and 
                                who provides direct care (including 
                                treatment and medications), who 
                                performs resident assessment and 
                                observation, who supervises direct 
                                patient care at the unit level, or who 
                                provides planning or coordination with 
                                other resident services.
                                    ``(II) Direct caregiver.--The term 
                                `direct caregiver' means a certified 
                                nurse assistant who provides direct 
                                care or a licensed nurse who provides 
                                direct care.
                                    ``(III) Day.--The term `day' means 
                                an eight-hour period commencing not 
                                earlier than 6 a.m. nor later than 8 
                                a.m.
                                    ``(IV) Evening.--The term `evening' 
                                means an eight-hour period commencing 
                                not earlier than 2 p.m. nor later than 
                                4 p.m.
                                    ``(V) Night.--The term `night' 
                                means an eight-hour period commencing 
                                not earlier than 10 p.m. nor later than 
                                12 midnight.''.
            (2) Higher standards.--Section 1819(f) of such Act (42 
        U.S.C. 1395i-3(f)) is amended by adding at the end the 
        following new paragraph:
            ``(8) Higher staffing standards for residents with higher 
        nursing care needs.--
                    ``(A) In general.--The Secretary may establish 
                higher minimum staffing requirements than those under 
                subsection (b)(4)(D), including for facilities with a 
                higher percentage of residents with extensive care 
                needs.
                    ``(B) Construction.--Nothing in this paragraph 
                shall be construed to prohibit a State from imposing 
                higher minimum staffing requirements than those under 
                subsection (b)(4)(D) or subparagraph (A).''.
            (3) Payment modification.--Section 1888(e)(4)(G) of such 
        Act is amended by adding at the end the following new clause:
                            ``(iv) Adjustment to reflect costs of 
                        minimum staffing.--The Secretary shall provide 
                        for an appropriate adjustment to account for 
                        the costs attributable to meeting the minimum 
                        staffing requirements of subsections (b)(4)(D) 
                        and (f)(8) of section 1819.''.
    (b) Medicaid-Funded Nursing Facilities.--
            (1) Minimum standards.--Section 1919(b)(4) of such Act (42 
        U.S.C. 1396r(b)(4)) is amended by adding at the end the 
        following new subparagraph:
                    ``(D) Minimum direct care staffing requirements.--
                            ``(i) Licensed nurses.--Subject to 
                        subsection (f)(8), a nursing facility must have 
                        at least one licensed nurse on duty on the 
                        premises for every--
                                    ``(I) 15 residents present during 
                                the day;
                                    ``(II) 20 residents present during 
                                the evening; and
                                    ``(III) 30 residents present during 
                                the night.
                            ``(ii) Direct caregivers.--Subject to 
                        subsection (f)(8), a nursing facility must have 
                        at least one direct caregiver on duty on the 
                        premises for every--
                                    ``(I) 5 residents present during 
                                the day;
                                    ``(II) 10 residents present during 
                                the evening; and
                                    ``(III) 15 residents present during 
                                the night.
                            ``(iii) Counting.--In determining 
                        compliance with the staffing levels under this 
                        subparagraph:
                                    ``(I) Administrative services.--In 
                                a facility with 60 or more beds, an 
                                individual may not be counted while 
                                performing noncaregiving administrative 
                                services.
                                    ``(II) Other services.--An 
                                individual may not be counted while 
                                performing food preparation, 
                                housekeeping, laundry, maintenance 
                                services, or other noncaregiving-
                                related activities.
                            ``(iv) Construction.--The staffing 
                        requirements of this subparagraph are in 
                        addition to the requirements of subparagraph 
                        (C).
                            ``(v) Definitions.--In this subparagraph:
                                    ``(I) Licensed nurse.--The term 
                                `licensed nurse' means a registered 
                                professional nurse, licensed practical 
                                nurse, or licensed vocational nurse who 
                                meets State licensing requirements and 
                                who provides direct care (including 
                                treatment and medications), who 
                                performs resident assessment and 
                                observation, who supervises direct 
                                patient care at the unit level, or who 
                                provides planning or coordination with 
                                other resident services.
                                    ``(II) Direct caregiver.--The term 
                                `direct caregiver' means a certified 
                                nurse assistant who provides direct 
                                care or a licensed nurse who provides 
                                direct care.
                                    ``(III) Day.--The term `day' means 
                                an eight-hour period commencing not 
                                earlier than 6 a.m. nor later than 8 
                                a.m.
                                    ``(IV) Evening.--The term `evening' 
                                means an eight-hour period commencing 
                                not earlier than 2 p.m. nor later than 
                                4 p.m.
                                    ``(V) Night.--The term `night' 
                                means an eight-hour period commencing 
                                not earlier than 10 p.m. nor later than 
                                12 midnight.''.
            (2) Higher standards.--Section 1919(f) of such Act (42 
        U.S.C. 1396r(f)) is amended by adding at the end the following 
        new paragraph:
            ``(8) Higher staffing standards for residents with higher 
        nursing care needs.--
                    ``(A) In general.--The Secretary may establish 
                higher minimum staffing requirements than those under 
                subsection (b)(4)(D), including for facilities with a 
                higher percentage of residents with extensive care 
                needs.
                    ``(B) Construction.--Nothing in this paragraph 
                shall be construed to prohibit a State from imposing 
                higher minimum staffing requirements than those under 
                subsection (b)(4)(D) or subparagraph (A).''.
            (3) Payment modification.--Section 1902(a)(13)(A) of such 
        Act is amended--
                    (A) in clause (iii), by striking the final ``and'';
                    (B) in clause (iv), by striking the semicolon and 
                inserting ``, and''; and
                    (C) by inserting after clause (iv) the following 
                new clause:
                            ``(v) in the case of nursing facilities, 
                        such rates take into account the costs 
                        attributable to the requirements of section 
                        1919(b)(4)(D).''.
    (c) Effective Date.--The amendments made by this section shall 
apply to services provided on or after the date that is two years after 
the date of enactment of this Act.
    (d) Report to Congress on Adequacy of Personnel To Meet Staffing 
Requirements.--Not later than one year after the date of enactment of 
this Act, the Secretary of Health and Human Services shall submit to 
the Congress a report regarding the adequacy of personnel in nursing 
facilities covered under titles XVIII and XIX of the Social Security 
Act to meet the direct care staffing requirements required under the 
amendments made by this Act to sections 1819(b)(4)(D) and 1919(b)(4)(D) 
of the Social Security Act (42 U.S.C. 1395i-3(b)(4)(D) and 
1396r(b)(4)(D)) and, if inadequate, recommendations on steps that 
should be taken to ensure that adequate numbers of trained staff are 
available to meet such requirements, including ways to attract and 
retain such direct caregiving personnel.

SEC. 3. DISCLOSURE OF STAFFING LEVELS AT MEDICARE- AND MEDICAID-FUNDED 
              NURSING FACILITIES.

    (a) Medicare-Funded Skilled Nursing Facilities.--
            (1) In general.--Section 1819(b)(4) of the Social Security 
        Act (42 U.S.C. 1395i-3(b)(4)), as amended by section 2(a)(1) of 
        this Act, is further amended by adding at the end the following 
        new subparagraph:
                    ``(E) Disclosure of staffing levels.--A skilled 
                nursing facility must conspicuously post the following 
                notices adjacent to each other in each area or unit to 
                which such notices apply in the facility in a manner 
                visible and accessible to residents, their families, 
                caregivers, and prospective residents of such facility 
                and in such a uniform format as the Secretary may 
                prescribe and must retain the information on such 
                notices for at least one year after posting and make 
                such information available upon request:
                            ``(i) Minimum staffing requirements.--A 
                        notice describing the minimum staffing 
                        requirements set forth in subparagraph (D) and, 
                        if applicable, subsection (f)(8).
                            ``(ii) Current staff information.--A notice 
                        showing, separately for each shift in the area 
                        or unit of the facility in which it is posted--
                                    ``(I) the current number of direct 
                                caregivers (including licensed nurses) 
                                present on the premises who perform 
                                resident care and the name and 
                                professional title of each such 
                                caregiver;
                                    ``(II) the current ratio of 
                                residents to licensed nurses present on 
                                the premises;
                                    ``(III) the current ratio of 
                                residents to direct caregivers 
                                (including licensed nurses) present on 
                                the premises; and
                                    ``(IV) the current number of 
                                residents of such area or unit.''.
            (2) Conforming amendment.--Section 1819(b)(4)(D)(v) of such 
        Act (42 U.S.C. 1395i-3(b)(4)(D)(v)), as added by section 
        2(a)(1) of this Act, is amended by inserting ``and subparagraph 
        (E)'' after ``this subparagraph''.
    (b) Medicaid-Funded Nursing Facilities.--
            (1) In general.--Section 1919(b)(4) of such Act (42 U.S.C. 
        1396r(b)(4)), as amended by section 2(b)(1) of this Act, is 
        further amended by adding at the end the following new 
        subparagraph:
                    ``(E) Disclosure of staffing levels.--A nursing 
                facility must conspicuously post the following notices 
                adjacent to each other in each area or unit to which 
                such notices apply in the facility in a manner visible 
                and accessible to residents, their families, 
                caregivers, and prospective residents of such facility 
                and in such a uniform format as the Secretary may 
                prescribe and must retain the information on such 
                notices for at least one year after posting and make 
                such information available upon request:
                            ``(i) Minimum staffing requirements.--A 
                        notice describing the minimum staffing 
                        requirements set forth in subparagraph (D) and, 
                        if applicable, subsection (f)(8).
                            ``(ii) Current staff information.--A notice 
                        showing, separately for each shift in the area 
                        or unit of the facility in which it is posted--
                                    ``(I) the current number of direct 
                                caregivers (including licensed nurses) 
                                present on the premises who perform 
                                resident care and the name and 
                                professional title of each such 
                                caregiver;
                                    ``(II) the current ratio of 
                                residents to licensed nurses present on 
                                the premises;
                                    ``(III) the current ratio of 
                                residents to direct caregivers 
                                (including licensed nurses) present on 
                                the premises; and
                                    ``(IV) the current number of 
                                residents of such area or unit.''.
            (2) Conforming amendment.--Section 1919(b)(4)(D)(v) of such 
        Act (42 U.S.C. 1396r(b)(4)(D)(v)), as added by section 2(b)(1) 
        of this Act, is amended by inserting ``and subparagraph (E)'' 
        after ``this subparagraph''.
    (c) Effective Date.--The amendments made by this section shall 
apply to services provided on or after the date that is two years after 
the date of enactment of this Act.

SEC. 4. ADMINISTRATIVE STAFFING REQUIREMENTS FOR MEDICARE- AND 
              MEDICAID-FUNDED NURSING FACILITIES.

    (a) Medicare-Funded Skilled Nursing Facilities.--
            (1) Minimum standards.--
                    (A) In general.--Section 1819(d)(1) of the Social 
                Security Act (42 U.S.C. 1395i-3(d)(1)) is amended by 
                adding at the end the following new subparagraph:
                    ``(D) Administrative staffing.--A skilled nursing 
                facility must maintain at least the administrative 
                staff described in the following clauses (i) through 
                (iv):
                            ``(i) Director of nursing services.--An 
                        individual who serves full time as a director 
                        of nursing services and who is a registered 
                        professional nurse.
                            ``(ii) Assistant director of nursing 
                        services.--An individual who serves full time 
                        as an assistant director of nursing services 
                        and who is a registered professional nurse, 
                        except that in a facility with fewer than 100 
                        beds, such individual may serve part time and 
                        may also serve as a direct care clinical 
                        nursing supervisor.
                            ``(iii) Director of in-service education.--
                        An individual who serves full time as a 
                        director of in-service education, who is a 
                        registered professional nurse, and who has, to 
                        the extent practicable and appropriate, 
                        training in adult education and gerontology, 
                        except that in a facility with fewer than 100 
                        beds, such individual may serve part time.
                            ``(iv) Direct care clinical nursing 
                        supervisor.--For each shift each day, an 
                        individual who serves full time as a direct 
                        care clinical nursing supervisor and who is a 
                        registered professional nurse, except that in a 
                        facility with fewer than 100 beds, such an 
                        individual may serve part time and may also 
                        serve as an assistant director of nursing.
                            ``(v) Limitation on fulfillment of 
                        administrative personnel requirements.--An 
                        individual cannot satisfy more than one 
                        requirement of clauses (i) through (iv), except 
                        as specifically provided.''.
                    (B) Conforming amendment.--Section 1819(b)(4)(D)(v) 
                of such Act (42 U.S.C. 1395i-3(b)(4)(D)(v)), as added 
                by section 2(a)(1) and amended by section 3(a)(2) of 
                this Act, is further amended by striking ``and 
                subparagraph (E)'' and inserting ``, subparagraph (E), 
                and subsection (d)(1)(D)''.
            (2) Payment modification.--Section 1888(e)(4)(G)(iv) of 
        such Act (42 U.S.C. 1395yy(e)(4)(G)(iv)), as added by section 
        2(a)(3) of this Act, is amended by striking ``section 
        1819(b)(4)(D)'' and inserting ``subsections (b)(4)(D) and 
        (d)(1)(D) of section 1819''.
    (b) Medicaid-Funded Nursing Facilities.--
            (1) Minimum standards.--
                    (A) In general.--Section 1919(d)(1) of such Act (42 
                U.S.C. 1396r(d)(1)) is amended by adding at the end the 
                following new subparagraph:
                    ``(D) Administrative staffing.--A nursing facility 
                must maintain at least the administrative staff 
                described in the following clauses (i) through (iv):
                            ``(i) Director of nursing services.--An 
                        individual who serves full time as a director 
                        of nursing services and who is a registered 
                        professional nurse.
                            ``(ii) Assistant director of nursing 
                        services.--An individual who serves full time 
                        as an assistant director of nursing services 
                        and who is a registered professional nurse, 
                        except that in a facility with fewer than 100 
                        beds, such individual may serve part time and 
                        may also serve as a direct care clinical 
                        nursing supervisor.
                            ``(iii) Director of in-service education.--
                        An individual who serves full time as a 
                        director of in-service education, who is a 
                        registered professional nurse, and who has, to 
                        the extent practicable and appropriate, 
                        training in adult education and gerontology, 
                        except that in a facility with fewer than 100 
                        beds, such individual may serve part time.
                            ``(iv) Direct care clinical nursing 
                        supervisor.--For each shift each day, an 
                        individual who serves full time as a direct 
                        care clinical nursing supervisor and who is a 
                        registered professional nurse, except that in a 
                        facility with fewer than 100 beds, such an 
                        individual may serve part time and may also 
                        serve as an assistant director of nursing.
                            ``(v) Limitation on fulfillment of 
                        administrative personnel requirements.--An 
                        individual cannot satisfy more than one 
                        requirement of clauses (i) through (iv), except 
                        as specifically provided.''.
                    (B) Conforming amendment.--Section 1919(b)(4)(D)(v) 
                of such Act (42 U.S.C. 1396r(b)(4)(D)(v)), as added by 
                section 2(b)(1) and amended by section 3(b)(2) of this 
                Act, is further amended by striking ``and subparagraph 
                (E)'' and inserting ``, subparagraph (E), and 
                subsection (d)(1)(D)''.
            (2) Payment modification.--Section 1902(a)(13)(A)(v) of 
        such Act (42 U.S.C. 1396a(a)(13)(A)(v)), as added by section 
        2(b)(3) of this Act, is amended by striking ``section 
        1919(b)(4)(D)'' and inserting ``subsections (b)(4)(D) and 
        (d)(1)(D) of section 1919''.
    (e) Effective Date.--The amendments made by this section shall 
apply to services provided on or after the date that is two years after 
the date of enactment of this Act.
                                 <all>