[Congressional Bills 106th Congress]
[From the U.S. Government Publishing Office]
[S. 3177 Introduced in Senate (IS)]







106th CONGRESS
  2d Session
                                S. 3177

  To require the Secretary of Health and Human Services to establish 
  minimum nursing staff levels for nursing facilities, to provide for 
grants to improve the quality of care furnished in nursing facilities, 
                        and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

            October 5 (legislative day, September 22), 2000

  Mr. Grassley (for himself, Mr. Breaux, and Mr. Reed) introduced the 
 following bill; which was read twice and referred to the Committee on 
                                Finance

_______________________________________________________________________

                                 A BILL


 
  To require the Secretary of Health and Human Services to establish 
  minimum nursing staff levels for nursing facilities, to provide for 
grants to improve the quality of care furnished in nursing facilities, 
                        and for other purposes.

    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 ``Nursing Home Staff Improvement Act 
of 2000''.

SEC. 2. FINDINGS.

    Congress makes the following findings:
            (1) Part I of the Health Care Financing Administration's 
        Report to Congress: Appropriateness of Minimum Nurse Staffing 
        Ratios in Nursing Homes was completed in August of 2000 and 
        showed the following:
                    (A) Quality of care may be significantly impaired 
                when staffing thresholds fall below 2.0 nurse aide 
                hours per resident day, 1.0 registered nurse and 
                licensed practical nurse hours per resident day and 
                0.45 registered nurse hours per resident day.
                    (B) Below this threshold, residents are more likely 
                to suffer life threatening illnesses secondary to 
                pressure sores, weight loss and preventable infections, 
                and rates of avoidable hospitalization increase 
                significantly.
                    (C) Fifty-four percent of nursing home facilities 
                do not provide 2.0 nurse aide hours per resident day 
                and approximately \1/2\ of nursing home facilities 
                would require greater than a 10 percent change in 
                staffing to meet this minimal standard.
                    (D) The 2.0 nurse aide hours per resident day is a 
                threshold below which residents lives are at risk, not 
                a standard for the provision of appropriate care.
            (2)(A) A minimum of 2.9 nurse aide hours per resident day 
        are necessary to deliver 5 necessary daily care services.
            (B) Over 92 percent of nursing home facilities fall below 
        the 2.9 nurse aide hours per resident day standard and would 
        require a 50 percent increase in staffing to meet this 
        standard.
            (C) The 2.9 nurse aide hours per resident day standard is 
        based on a conservative assumption and understates the real 
        staffing levels necessary for a nurse aide to complete all 
        tasks that constitute adequate care.
            (3)(A) Facilities that serve residents with more complex 
        medical conditions will require higher staffing levels.
            (B) Minimum staffing levels that take into account case mix 
        have not yet been established.
            (C) Part II of the Health Care Financing Administration 
        report, which has not yet been completed, will report to 
        Congress on minimum staffing levels according to the facility's 
        resident acuity level.

SEC. 3. COMPLETION OF REPORT TO CONGRESS ON ADEQUATE NURSING FACILITY 
              STAFFING REQUIREMENTS.

    (a) In General.--Section 4801(e)(17)(B) of the Omnibus Budget 
Reconciliation Act of 1990 (42 U.S.C. 1396r note) is amended--
            (1) by striking ``January 1, 1999'' and inserting ``July 1, 
        2001'';
            (2) by inserting ``and optimal minimum'' after ``minimum'' 
        each place it appears;
            (3) by striking the period and inserting a semicolon;
            (4) by striking ``such study recommendations'' and 
        inserting ``such study--
                            ``(i) recommendations''; and
            (5) by adding at the end the following:
                            ``(ii) an examination of the cost and 
                        benefits associated with establishing staffing 
                        minimum and optimal minimum ratios;
                            ``(iii) a description of the data used in 
                        Phase II of the study to expand the 
                        multivariate analysis from 3 States to a more 
                        representative national sample;
                            ``(iv) an analysis of proposed refined case 
                        mix classification methods considered in Phase 
                        II of the study;
                            ``(v) a description of the case studies 
                        used to validate the Phase I findings of the 
                        study; and
                            ``(vi) an examination of other issues that 
                        impact the recruitment and retention of 
                        certified nursing assistants.''.
    (b) Effective Date.--The amendments made by subsection (a) take 
effect as if included in the enactment of section 4801 of the Omnibus 
Budget Reconciliation Act of 1990 (Public Law 101-508; 104 Stat. 1388-
211).

SEC. 4. ESTABLISHMENT OF APPROPRIATE MINIMUM STAFFING REQUIREMENTS.

    (a) Notice of Proposed Rulemaking.--Not later than 6 months after 
the date that the Secretary of Health and Human Services (in this 
section referred to as the ``Secretary'') submits the report to 
Congress required under section 4801(e)(17)(B) of the Omnibus Budget 
Reconciliation Act of 1990 (42 U.S.C. 1396r note) regarding the study 
of establishing appropriate minimum caregiver to resident levels and 
appropriate minimum supervisor to caregiver levels for skilled nursing 
facilities participating as providers of services under the medicare 
program under title XVIII of the Social Security Act (42 U.S.C. 1395 et 
seq.) and nursing facilities receiving payments under the medicaid 
program under title XIX of such Act (42 U.S.C. 1396 et seq.) that 
includes recommendations regarding appropriate minimums for such 
levels, the Secretary shall issue a notice of proposed rule-making with 
respect to the promulgation of a final regulation requiring compliance 
with appropriate minimum caregiver to resident levels and appropriate 
minimum supervisor to caregiver levels as a condition for such 
facilities to receive payments under such programs.
    (b) Final Regulation.--Not later than 6 months after the issuance 
of the notice required under subsection (a), the Secretary shall issue 
the final regulation (to be effective upon publication) that was the 
subject of such notice.
    (c) Definition of Appropriate.--In this section, the term 
``appropriate'' means the staffing threshold level required to attain a 
good or optimal quality outcome with respect to a resident of a skilled 
nursing facility participating as a provider of services under the 
medicare program under title XVIII of the Social Security Act (42 
U.S.C. 1395 et seq.) or of a nursing facility receiving payments under 
the medicaid program under title XIX of such Act (42 U.S.C. 1396 et 
seq.), as opposed to avoiding a bad outcome with respect to such a 
resident.

SEC. 5. GRANTS TO IMPROVE STAFFING LEVELS AND THE QUALITY OF CARE IN 
              NURSING FACILITIES.

    (a) Authority To Award Grants.--The Secretary of Health and Human 
Services shall award grants to States on a competitive basis for the 
purpose of improving staffing levels in nursing facilities in order to 
improve the quality of care to residents of such facilities.
    (b) Applications.--Each State 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 may require, except 
that any such application shall include at least a certification that 
the application was developed through an open, public process.
    (c) Requirements for Use of Funds.--
            (1) Permissible uses.--
                    (A) In general.--A State awarded a grant under this 
                section shall use funds provided under the grant to 
                provide financial support or technical assistance for 
                projects operated by nursing facilities, labor 
                organizations, nonprofit organizations, community 
                colleges, or other organizations, or through joint 
                efforts of such entities and organizations, that are 
                designed to do any or all of the following:
                            (i) Enhance staff recruitment and retention 
                        efforts.
                            (ii) Establish centers of expertise and 
                        training.
                            (iii) Establish career ladders for 
                        certified nurse assistants, including 
                        additional or advanced training opportunities.
                            (iv) Provide additional training for 
                        nursing facility direct care staff.
                            (v) Improve workplace safety.
                            (vi) Improve nursing facility management.
                            (vii) Conduct other staffing initiatives to 
                        improve patient outcomes, as approved by the 
                        Secretary.
                    (B) Applicability of nursing home reform 
                provisions.--Funds made available under a grant awarded 
                to a State under this section may only be used to 
                provide financial support or technical assistance for 
                any project described in subparagraph (A) to the extent 
                that the activities conducted under the project are 
                consistent with the requirements of sections 1818 and 
                1919 of the Social Security Act (42 U.S.C. 1395i-3, 
                1396r).
                    (C) Prohibition.--No funds made available under a 
                grant awarded to a State under this section may be used 
                to provide financial support or technical assistance 
                for any project described in subparagraph (A) that is 
                conducted at, or for the benefit of, a nursing facility 
                that is owned or operated by a State, county, or local 
                government.
            (2) No supplantation of funds.--Funds made available under 
        a grant awarded to a State under this section may only be used 
        to supplement, not supplant, other funds that the State expends 
        to carry out activities described in paragraph (1)(A).
    (d) Authorization of Appropriations.--There are authorized to be 
appropriated to the Secretary for purposes of carrying out this section 
$500,000,000 for each of fiscal years 2001 and 2002. Funds appropriated 
in accordance with this subsection for a fiscal year shall remain 
available through the end of the succeeding fiscal year.
    (e) Reports and Secretarial Evaluation.--
            (1) State final reports.--Each State that is awarded a 
        grant under this section shall submit a final report to the 
        Secretary on the use of funds awarded under the grant not later 
        than 3 months after the earlier of--
                    (A) the completion of the project or projects 
                provided financial support or technical assistance with 
                funds received under the grant; or
                    (B) the conclusion of the 2-year period that begins 
                on the date that the State receives such grant funds.
            (2) Secretarial evaluation and report.--Not later than 6 
        months after the final State report is submitted to the 
        Secretary under paragraph (1), the Secretary shall submit to 
        Congress a report evaluating the extent to which the grant 
        program established under this section assists States in 
        improving staffing levels in nursing facilities.
    (f) Definitions.--In this section:
            (1) Nursing facility.--The term ``nursing facility'' means 
        a skilled nursing facility participating in the medicare 
        program established under title XVIII of the Social Security 
        Act (42 U.S.C. 1395 et seq.) or a nursing facility receiving 
        payments under the medicaid program established under title XIX 
        of such Act (42 U.S.C. 1396 et seq.).
            (2) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.

SEC. 6. PROVIDING ACCURATE INFORMATION ON STAFFING.

    (a) Medicare.--
            (1) Data on staffing levels.--Section 1819(b) of the Social 
        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 levels.--
                    ``(A) In general.--A skilled nursing facility shall 
                submit to the Secretary, at such time as the Secretary 
                shall specify and on a standard reporting format 
                developed by the Secretary, data with respect to 
                nursing staff that--
                            ``(i) includes the total number of nursing 
                        staff hours and coverage levels per shift 
                        furnished 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; 
                        and
                            ``(ii) is attested to in writing by the 
                        facility as accurate.
                    ``(B) Publication of data.--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-specific nursing 
                staff information described in subparagraph (A). The 
                Secretary shall update such information 
                periodically.''.
            (2) Information concerning patient classification.--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) Information concerning residents.--The 
                skilled nursing facility shall provide the Secretary, 
                in such form and manner and at such intervals as the 
                Secretary may require, a classification of all 
                residents of the skilled nursing facility that accords 
                with the resident classification system described in 
                section 1888(e)(4)(G)(i), or such successor system as 
                the Secretary may identify.''.
    (b) Medicaid.--
            (1) Data on staffing levels.--Section 1919(b) of the Social 
        Security Act (42 U.S.C. 1396r(b)) is amended by adding at the 
        end the following new paragraph:
            ``(8) Submission of data on staffing levels.--
                    ``(A) In general.--A nursing facility shall submit 
                to the Secretary, at such time as the Secretary shall 
                specify and on a standard reporting format developed by 
                the Secretary, data with respect to nursing staff 
                that--
                            ``(i) includes the total number of nursing 
                        staff hours and coverage levels per shift 
                        furnished by the facility to residents for 
                        which payment is made under the State plan, 
                        broken down by total certified nurse aide 
                        hours, total licensed practical or vocational 
                        nurse hours, and total registered nurse hours; 
                        and
                            ``(ii) is attested to in writing by the 
                        facility as accurate.
                    ``(B) Publication of data.--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-specific nursing 
                staff information described in subparagraph (A). The 
                Secretary shall update such information 
                periodically.''.
            (2) Information concerning patient classification.--Section 
        1919(b)(4) of the Social Security Act (42 U.S.C. 1395r(b)(4)) 
        is amended by adding at the end the following new subparagraph:
                    ``(D) Information concerning residents.--The 
                nursing facility shall provide the Secretary, in such 
                form and manner and at such intervals as the Secretary 
                may require, a classification of all residents of the 
                nursing facility that accords with the resident 
                classification system described in section 
                1888(e)(4)(G)(i), or such successor system as the 
                Secretary may identify.''.

SEC. 7. INFORMATION ON NURSING FACILITY STAFFING.

    (a) Medicare Amendments.--Section 1819(b) of the Social Security 
Act (42 U.S.C. 1395i-3(b)), as amended by section 6(a), is further 
amended by adding at the end the following new paragraph:
            ``(9) Information on nurse staffing.--A skilled nursing 
        facility shall post daily for each nursing unit of the facility 
        and for each shift the current number of licensed and 
        unlicensed nursing staff directly responsible for resident care 
        and the number of residents per unit and per shift. The 
        information shall be displayed in a uniform manner and in a 
        clearly visible place.''.
    (b) Medicaid Amendments.--Section 1919(b) of the Social Security 
Act (42 U.S.C. 1396r(b)), as amended by section 6(b), is amended by 
adding at the end the following new paragraph:
            ``(9) Information on nurse staffing.--A nursing facility 
        shall post daily for each nursing unit of the facility and for 
        each shift the current number of licensed and unlicensed 
        nursing staff directly responsible for resident care and the 
        number of residents per unit and per shift. The information 
        shall be displayed in a uniform manner and in a clearly visible 
        place.''.
    (c) Effective Date.--The amendments made by this section 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.
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