[Congressional Bills 108th Congress]
[From the U.S. Government Publishing Office]
[H.R. 787 Introduced in House (IH)]







108th CONGRESS
  1st Session
                                H. R. 787

 To amend titles XVIII and XIX of the Social Security Act with respect 
   to reform of Federal survey and certification process of nursing 
          facilities under the Medicare and Medicaid Programs.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           February 13, 2003

   Mr. Camp introduced the following bill; which was referred to the 
Committee on Ways and Means, and in addition to the Committee on Energy 
    and 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 with respect 
   to reform of Federal survey and certification process of nursing 
          facilities under the Medicare and Medicaid Programs.

    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 ``Medicare and Medicaid Nursing 
Facility Quality Improvement Act of 2003''.

SEC. 2. QUALITY IMPROVEMENT FOR NURSING FACILITIES UNDER THE MEDICARE 
              AND MEDICAID PROGRAMS.

    (a) Incentives for Immediate Improvement and Protection of Needed 
Training Programs.--
            (1) Medicare program.--Section 1819(f)(2) of the Social 
        Security Act (42 U.S.C. 1395i-3(f)(2)) is amended--
                    (A) in subparagraph (B)(iii), by striking 
                ``subparagraph (C)'' and inserting ``subparagraphs (C) 
                and (D)''; and
                    (B) by adding at the end the following new 
                subparagraph:
                    ``(D) Restoration of nurse aide training upon 
                demonstration of compliance.--The prohibition on 
                program approval described in subparagraph (B)(iii)(I) 
                shall not be continued when the facility involved 
                through on-site verification demonstrates compliance 
                with the applicable standards.''.
            (2) Medicaid program.--Section 1919(f)(2) of such Act (42 
        U.S.C. 1396r(f)(2)) is amended--
                    (A) in subparagraph (B)(iii), by striking 
                ``subparagraph (C)'' and inserting ``subparagraphs (C) 
                and (D)''; and
                    (B) by adding at the end the following new 
                subparagraph:
                    ``(D) Restoration of nurse aide training upon 
                demonstration of compliance.--The prohibition on 
                program approval described in subparagraph (B)(iii)(I) 
                shall not be continued when the facility involved 
                through on-site verification demonstrates compliance 
                with the applicable standards.''.
    (b) Requirements for Nurse Aide Training.--
            (1) Medicare program.--Section 1819(f)(2)(B)(iii)(I) of 
        such Act (42 U.S.C. 1395i-3(f)(2)(B)(iii)(I)) is amended--
                    (A) in the matter before subdivision (a), by 
                striking ``, within the previous 2 years'';
                    (B) in subdivision (a), by striking ``has 
                operated'' and inserting ``is operating'';
                    (C) in subdivision (b), by striking ``has been 
                subject'' and inserting ``is subject''; and
                    (D) in subdivision (c), by inserting ``within the 
                previous 2 years'' after ``(c)''.
            (2) Medicaid program.--Section 1919(f)(2)(B)(iii)(I) of 
        such Act (42 U.S.C. 1396r(f)(2)(B)(iii)(I)) is amended--
                    (A) in the matter before subdivision (a), by 
                striking ``, within the previous 2 years'';
                    (B) in subdivision (a), by striking ``has 
                operated'' and inserting ``is operating'';
                    (C) in subdivision (b), by striking ``has been 
                subject'' and inserting ``is subject''; and
                    (D) in subdivision (c), by inserting ``within the 
                previous 2 years'' after ``(c)''.
    (c) Promoting Innovation and Quality Improvement Through State 
Waivers.--
            (1) Medicare program.--Section 1819(g) of such Act (42 
        U.S.C. 1395i-3(g)) is amended by adding at the end the 
        following new paragraph:
            ``(6) Waiver demonstration authority to promote innovation 
        and quality improvement.--
                    ``(A) In general.--At the request of a State, but 
                not to exceed a total of 8 States, the Secretary may 
                waive provisions of this subsection relating to survey 
                and certification procedures in order to test and 
                implement innovative alternatives to the survey process 
                otherwise applicable. The Secretary shall provide 
                special consideration to the application of alternative 
                procedures that increase the use of outcome  measures, 
the incorporation of quality of life measures, and improve consistency 
and accuracy in deficiency determinations and survey results. The 
Secretary shall approve a waiver request if applicant demonstrates 
significant potential for improving the quality of care, quality of 
life, and safety of residents.
                    ``(B) Consideration of views of stakeholders.--The 
                Secretary shall only consider waiver applications under 
                this paragraph from a State under this paragraph if the 
                State has convened and consulted with appropriate 
                stakeholders in the State, including representatives of 
                nursing facilities, consumers groups, the State long 
                term care ombudsman, labor organizations (and where 
                such organizations are not present in the industry, 
                other employee representatives), and licensed health 
                care providers, to assist in developing their 
                alternative system. In determining whether to grant 
                such waivers the Secretary shall take into 
                consideration the views of the stakeholders convened by 
                the State.''.
            (2) Medicaid program.--Section 1919(g) of such Act (42 
        U.S.C. 1396r(g)) is amended by adding at the end the following 
        new paragraph:
            ``(6) Waiver demonstration authority to promote innovation 
        and quality improvement.--
                    ``(A) In general.--At the request of a State, but 
                not to exceed a total of 8 States, the Secretary may 
                waive provisions of this subsection relating to survey 
                and certification procedures in order to test and 
                implement innovative alternatives to the survey process 
                otherwise applicable. The Secretary shall provide 
                special consideration to the application of alternative 
                procedures that increase the use of outcome measures, 
                the incorporation of quality of life measures, and 
                improve consistency and accuracy in deficiency 
                determinations and survey results. The Secretary shall 
                approve a waiver request if it demonstrates significant 
                potential for improving the quality of care, quality of 
                life, and safety of residents.
                    ``(B) Consideration of views of stakeholders.--The 
                Secretary shall only consider waiver applications under 
                this paragraph from a State under this paragraph if the 
                State has convened and consulted with appropriate 
                stakeholders in the State, including representatives of 
                nursing facilities, consumers groups, the State long 
                term care ombudsman, labor organizations (and where 
                such organizations are not present in the industry, 
                other employee representatives), and licensed health 
                care providers, to assist in developing their 
                alternative system. In determining whether to grant 
                such waivers the Secretary shall take into 
                consideration the views of the stakeholders convened by 
                the State.''.
    (d) Removal of Inflexibility in Provider Termination.--
            (1) Medicare program.--Section 1819(h)(2) of such Act (42 
        U.S.C. 1395i-3(h)(2)) is amended--
                    (A) in subparagraph (D), by striking ``If'' and 
                inserting ``Subject to subparagraph (F), if'';
                    (B) in subparagraph (E), by striking ``In'' and 
                inserting ``Subject to subparagraph (F), in''; and
                    (C) by adding at the end the following new 
                subparagraph:
                    ``(F) Continuation of payments pending remediation 
                when flexibility needed to protect residents.--The 
                Secretary may continue payments, over a period not 
                longer than 12 months after the effective date of the 
                findings, under this title with respect to a nursing 
                facility not in compliance with a requirement of 
                subsection (b), (c), or (d), if--
                            ``(i) the State survey agency finds that 
                        ceasing payments is not in the best interests 
                        of residents and that continuation of payments 
                        would not jeopardize residents' health and 
                        safety;
                            ``(ii) the State survey agency finds that 
                        it is more appropriate to take alternative 
                        action to assure compliance of the  facility 
with the requirements than to terminate the certification of the 
facility; and
                            ``(iii) the State has submitted a plan and 
                        timetable for corrective action to the 
                        Secretary for approval and the Secretary 
                        approves the plan of corrective action.''.
            (2) Medicaid program.--Section 1919(h)(2) of such Act (42 
        U.S.C. 1396r(h)(2)) is amended--
                    (A) in subparagraph (C), by striking ``If'' and 
                inserting ``Subject to subparagraph (G), if'';
                    (B) in subparagraph (D), by striking ``In'' and 
                inserting ``Subject to subparagraph (G), in''; and
                    (C) by adding at the end the following new 
                subparagraph:
                    ``(G) Continuation of payments pending remediation 
                when flexibility needed to protect residents.--The 
                Secretary may continue payments, over a period not 
                longer than 12 months after the effective date of the 
                findings, under this title with respect to a nursing 
                facility not in compliance with a requirement of 
                subsection (b), (c), or (d), if--
                            ``(i) the State survey agency finds that 
                        ceasing payments is not in the best interests 
                        of residents and that continuation of payments 
                        would not jeopardize residents' health and 
                        safety;
                            ``(ii) the State survey agency finds that 
                        it is more appropriate to take alternative 
                        action to assure compliance of the facility 
                        with the requirements than to terminate the 
                        certification of the facility; and
                            ``(iii) the State has submitted a plan and 
                        timetable for corrective action to the 
                        Secretary for approval and the Secretary 
                        approves the plan of corrective action.''.
    (e) Access to Informal Dispute Resolution Process.--
            (1) Medicare program.--Section 1819(g)(1) of such Act (42 
        U.S.C. 1395i-3(g)(1)) is amended by adding at the end the 
        following new subparagraph:
                    ``(F) Establishment of informal, independent 
                dispute resolution process.--Each State shall establish 
                an informal dispute resolution process that allows 
                facilities to settle disputes involving compliance with 
                the standards established under this section. Such 
                process shall rely on independent third parties, not 
                related to the State survey agency or the facilities, 
                in resolving disputes.''.
            (2) Medicaid program.--Section 1919(g)(1) of such Act (42 
        U.S.C. 1396r(g)(1)) is amended by adding at the end the 
        following new subparagraph:
                    ``(F) Establishment of informal, independent 
                dispute resolution process.--Each State shall establish 
                an informal dispute resolution process that allows 
                facilities to settle disputes involving compliance with 
                the standards established under this section. Such 
                process shall rely on independent third parties, not 
                related to the State survey agency or the facilities, 
                in resolving disputes.''.
    (f) Deference to Attending Physician Diagnosis and Treatment 
Decisions During the Survey Process.--
            (1) Medicare program.--Section 1819(g)(2) of such Act (42 
        U.S.C. 1395i-3(g)(2)) is amended by inserting at the end the 
        following new subparagraph:
                    ``(F) Deference to attending physician diagnosis 
                and treatment.--
                            ``(i) In general.--In the conduct of any 
                        surveys under this subsection and the 
                        compliance decisions made thereunder, surveyors 
                        shall defer to the diagnosis and treatment 
                        decisions of the resident's attending physician 
                        and of the facility's medical director, and to 
                        a plan of care established pursuant to 
                        subsection (b)(2), as long as such decisions 
                        and plans are consistent with acceptable 
                        standards of practice.
                            ``(ii) Failure to defer to treating 
                        decision.--Each State and the Secretary shall 
                        implement programs to monitor and correct 
                        instances of failure of surveyors to adhere to 
                        the requirements of this subparagraph.''.
            (2) Medicaid program.--Section 1919(g)(2) of such Act (42 
        U.S.C. 1396r(g)(2)) is amended by inserting at the end the 
        following new subparagraph:
                    ``(F) Deference to attending physician diagnosis 
                and treatment.--
                            ``(i) In general.--In the conduct of any 
                        surveys under this subsection and the 
                        compliance decisions made thereunder, surveyors 
                        shall defer to the diagnosis and treatment 
                        decisions of the resident's attending physician 
                        and of the facility's medical director, and to 
                        a plan of care established pursuant to 
                        subsection (b)(2), as long as such decisions 
                        and plans are consistent with acceptable 
                        standards of practice.
                            ``(ii) Failure to defer to treating 
                        decision.--The State and the Secretary shall 
                        implement programs to monitor and correct 
                        instances of failure of surveyors to adhere to 
                        the requirements of this subparagraph.''.
    (g) Dissemination of Information on Best Practices.--
            (1) Medicare program.--Section 1819(g)(2)(E) of such Act 
        (42 U.S.C. 1395i-3(g)(2)(E)) is amended by adding at the end 
        the following new clause:
                            ``(iv) Permitting dissemination of 
                        information on best and innovative practices.--
                        Nothing in this section shall be construed as 
                        precluding a member of a survey team from 
                        providing information to facility staff on best 
                        or innovative practices in complying with the 
                        requirements of this section.''.
            (2) Medicaid program.--Section 1919(g)(2)(E) of such Act 
        (42 U.S.C. 1396r(g)(2)(E)) is amended by adding at the end the 
following new clause:
                            ``(iv) Permitting dissemination of 
                        information on best and innovative practices.--
                        Nothing in this section shall be construed as 
                        precluding a member of a survey team from 
                        providing information to facility staff on best 
                        or innovative practices in complying with the 
                        requirements of this section.''.
    (h) Removing Barriers That Deter New Management From Taking Over 
and Improving Problem Facilities.--
            (1) Medicare program.--Section 1819(h) of such Act (42 
        U.S.C. 1395i-3(h)) is amended by adding at the end the 
        following new paragraph:
            ``(7) Fostering improvement of facilities with poor 
        compliance histories.--The Secretary shall provide incentives 
        for operators with histories of good compliance to acquire 
        facilities with poor compliance histories. Such incentives 
        shall be designed to promote the sustained provision of high-
        quality care and shall only be made available in the case of 
        bona fide, arm's-length sale of facilities with poor compliance 
        histories.''.
            (2) Medicaid program.--Section 1919(h) of such Act (42 
        U.S.C. 1396r(h)) is amended by adding at the end the following 
        new paragraph:
            ``(10) Fostering improvement of facilities with poor 
        compliance histories.--The Secretary shall provide incentives 
        for operators with histories of good compliance to acquire 
        facilities with poor compliance histories. Such incentives 
        shall be designed to promote the sustained provision of high-
        quality care and shall only be made available in the case of 
        bona fide, arm's-length sale of facilities with poor compliance 
        histories.''.
    (i) Allowing Appeals of All Deficiencies.--
            (1) Medicare program.--Section 1819(h) of such Act, as 
        amended by subsection (g)(1), is further amended by adding at 
        the end the following new paragraph:
            ``(8) Right to appeal all deficiency citations.--
        Notwithstanding any other provision of law, a facility may 
        appeal any deficiency determination under this section with 
        respect to which a penalty has not been imposed in the same 
        manner as the facility may appeal such determination if a 
        penalty had been imposed.''.
            (2) Medicaid program.--Section 1919(h) of such Act, as 
        amended by subsection (g)(2), is further amended by adding at 
        the end the following new paragraph:
            ``(11) Right to appeal all deficiency citations.--
        Notwithstanding any other provision of law, a facility may 
        appeal any deficiency determination under this section with 
        respect to which a penalty has not been imposed in the same 
        manner as the facility may appeal such determination if a 
        penalty had been imposed.''.
    (j) Encouragement of Excellence in Nursing Facility Care.--
            (1) Medicare program.--Section 1819(h)(2) of such Act is 
        amended by adding at the end the following new subparagraph:
                    ``(F) Award programs.--The Secretary shall 
                establish a program that rewards skilled nursing 
                facilities that provide the highest quality care in a 
                manner similar to that required to be established by 
                States under section 1919(h)(2)(F). Such program may 
                use public recognition, incentive payments, or other 
                means.''.
            (2) Medicaid program.--Section 1919(h)(2)(F) of such Act is 
        amended by striking ``may establish'' and inserting ``shall 
        establish''.
    (k) Effective Date.--The amendments made by this section shall take 
effect 1 month after the date of the enactment of this Act except in 
cases where regulations are needed to implement these changes and in 
such cases shall be effective 6 months after such enactment date.
                                 <all>