[Congressional Bills 112th Congress]
[From the U.S. Government Publishing Office]
[S. 2022 Introduced in Senate (IS)]

112th CONGRESS
  1st Session
                                S. 2022

To establish a demonstration program to test the viability of community 
               integrated small-house nursing care homes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                           December 16, 2011

    Mr. Casey (for himself, Mr. Enzi, Mr. Schumer, and Mr. Wicker) 
introduced the following bill; which was read twice and referred to the 
                          Committee on Finance

_______________________________________________________________________

                                 A BILL


 
To establish a demonstration program to test the viability of community 
               integrated small-house nursing care homes.

    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 ``Community Integrated Nursing Care 
Homes Demonstration Program Act'' or the ``CINCH Demonstration Program 
Act''.

SEC. 2. DEFINITIONS.

    In this Act:
            (1) CINCH demonstration program.--The term ``CINCH 
        demonstration program'' means the demonstration program 
        conducted under this Act.
            (2) Medicaid.--The term ``Medicaid'' means the program for 
        medical assistance established under title XIX of the Social 
        Security Act (42 U.S.C. 1396 et seq.).
            (3) Medicare.--The term ``Medicare'' means the program for 
        medical assistance established under title XVIII of the Social 
        Security Act (42 U.S.C. 1395 et seq.).
            (4) Nursing home.--The term ``nursing home'' means--
                    (A) a skilled nursing facility (as defined in 
                section 1819(a) of the Social Security Act (42 U.S.C. 
                1395i-3(a))); or
                    (B) a nursing facility (as defined in section 
                1919(a) of the Social Security Act (42 U.S.C. 
                1396r(a))).
            (5) Research-based.--The term ``research-based'' means 
        research that--
                    (A) has been conducted by an objective researcher 
                or research team that has--
                            (i) no financial or affiliated 
                        organizational interest in the success of the 
                        model; and
                            (ii) expertise in long-term care, with not 
                        less than 3 research articles relating to long-
                        term care that have been published in leading 
                        peer-reviewed journals;
                    (B) has been conducted according to generally 
                accepted research practices;
                    (C) has been published in a leading peer-reviewed 
                journal on aging or long-term care; and
                    (D) indicates a measurable improvement in multiple 
                aspects of quality of life and care.
            (6) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.
            (7) Rural area.--The term ``rural area'' means any area 
        other than an urban or suburban area.
            (8) Suburban area.--The term ``suburban area'' means any 
        urbanized area that is contiguous and adjacent to an urban 
        area.
            (9) Urban area.--The term ``urban area'' means a city or 
        town that has a population of greater than 50,000 inhabitants.

SEC. 3. SMALL-HOUSE NURSING CARE HOME REQUIREMENTS.

    To be eligible to participate in the CINCH demonstration program as 
a small-house nursing care home, a nursing home shall--
            (1) subject to section 4(f), have been certified by a 
        Federal, State, or local entity (in accordance with applicable 
        Federal, State, and local law) to operate a nursing home;
            (2) operate in compliance with any direct care and 
        certified nurse assistant staffing requirements under Federal, 
        State, and local law;
            (3) provide nursing home services, as required under State 
        law and applicable licensing standards, that shall not be less 
        comprehensive or high-acuity than services provided by the 
        eligible operating entity within the immediate surrounding 
        community;
            (4) provide for meals cooked in the nursing home and not 
        prepared in a central kitchen and transported to the home;
            (5) provide for a universal worker approach to resident 
        care (such as a certified nursing assistant who provides 
        personal care, socialization services, meal preparation 
        services, and laundry and housekeeping services);
            (6) provide for direct care staffing at a rate that meets 
        applicable Federal and State requirements or that is not less 
        than 4 hours per resident per day, whichever is greater, with 
        direct care staff (including certified nurse assistants) to be 
        onsite, awake, and available within each small-house nursing 
        care home at all times;
            (7) provide for direct nursing care at a rate that meets 
        applicable Federal and State requirements or that is not less 
        than 1 hour per resident per day, whichever is greater, with a 
        nursing staff that is awake and available at each location at 
        all times and that meets or exceeds applicable Federal and 
        State requirements for qualifications, services, and 
        availability;
            (8) provide for any other clinical, operational, 
        management, or facility staff and services as required under 
        applicable Federal and State requirements, with such staff to 
        be available from centralized or distributed locations, 
        including a director of nursing who shall be responsible for 
        oversight of the nursing staff within a site;
            (9) provide for consistent staff assignments and self-
        directed work teams of direct care staff;
            (10) provide training for all staff involved in the 
        operations of the nursing home (for not less than 120 hours for 
        each universal worker and not less than 60 hours for each 
        leadership and clinical team member, to be completed for the 
        majority of the staff before they start to work in a small-
        house nursing care home) concerning the philosophy, operations, 
        and skills required to implement and maintain self-directed 
        care, self-managed work teams, a noninstitutional approach to 
        life and care in long-term care, appropriate safety and 
        emergency skills, cooking from scratch by the direct care staff 
        and food handling and safety, and other elements required for 
        successful operation of the small-house nursing care home;
            (11) ensure that the percentage of residents in each small-
        house nursing care home who are short-stay rehabilitation 
        residents does not exceed 20 percent at any time (unless the 
        small-house nursing care home is entirely devoted to providing 
        rehabilitation services), except that a long-term resident 
        transferring back to a small-house nursing care home after an 
        acute episode and who is receiving rehabilitation services for 
        which payment is made under Medicare shall not be counted 
        toward such limitation;
            (12) provide the technical assistance provider with Minimum 
        Data Set (``MDS'') information and financial data in a timely 
        manner on a monthly basis; and
            (13) consist of a physical environment designed to look and 
        feel like a home, rather than an institution, and that shall--
                    (A) be designed to serve as a fully independent, 
                self-sufficient, and disabled accessible house or 
                apartment that is similar to housing available within 
                the immediate surrounding community, with not more than 
                10 residents within such house or apartment, and that 
                shall only be connected to or share areas that would be 
                generally shared between private homes (such as a 
                driveway) or apartments (such as a lobby or laundry 
                room);
                    (B) contain residential-style design elements and 
                materials throughout the home that are similar to those 
                in the immediate surrounding community and that do not 
                use commercial and institutional elements and products 
                (such as a nurses' station, medication carts, hospital 
                or office-type florescent lighting, acoustical tile 
                ceilings, institutional-style railings and corner 
                guards, and room numbering and labeling) unless 
                mandated by authorities with appropriate jurisdiction 
                over the nursing home;
                    (C) provide private, single occupancy bedrooms 
                that--
                            (i) are shared only at the request of a 
                        resident to accommodate a spouse, partner, 
                        family member, or friend, and that contains a 
                        full private bathroom that includes, at a 
                        minimum, a toilet, sink, and accessible shower; 
                        and
                            (ii) are dually certified for occupancy by 
                        a Medicaid or Medicare eligible individual;
                    (D) contain a living area where residents and staff 
                may socialize, dine, and prepare food together that 
                provides, at a minimum, a living room seating area, a 
                dining area large enough for a single table serving all 
                residents and not less than 2 staff members, and a full 
                kitchen that is open to the living and dining areas;
                    (E) contain ample natural light in each habitable 
                space that is provided through exterior windows and 
                other means, with window areas, exclusive of skylights 
                and clerestories, being a minimum of 10 percent of the 
                area of the room;
                    (F) have a life-safety rating that is sufficient to 
                meet State and local standards for nursing facilities, 
                including such provisions of such edition (as specified 
                by the Secretary in regulation) of the Life Safety Code 
                of the National Fire Protection Association as are 
                applicable to nursing homes, appropriately accommodate 
                individuals who cannot evacuate the small-house nursing 
                care home without assistance, and satisfy applicable 
                requirements under the Americans with Disabilities Act 
                of 1990 (42 U.S.C. 12101 et seq.); and
                    (G) contain built-in safety features to allow all 
                areas of the small-house nursing care home to be 
                accessible to residents during the majority of the day 
                and night.

SEC. 4. ESTABLISHMENT OF COMMUNITY INTEGRATED NURSING CARE HOMES 
              DEMONSTRATION PROGRAM.

    (a) In General.--The Secretary shall establish the CINCH 
demonstration program to test the viability of multiple small-house 
nursing care homes that are embedded within residential neighborhoods 
and collectively certified to provide services through a single 
eligible operating entity in order to reduce administrative costs and 
provide related cost savings to the Medicare and Medicaid programs.
    (b) Duration and Scope.--
            (1) Duration.--The Secretary shall conduct the CINCH 
        demonstration program for a period of 5 years.
            (2) Scope.--The Secretary shall select not more than 6 
        sites (as described in subsection (c)(2)) to participate in the 
        CINCH demonstration program, with each site to be operated by a 
        different eligible operating entity (as described under section 
        5(b)), with not less than 2 sites to be located in rural areas.
    (c) Structure of Demonstration Program.--
            (1) Eligible operating entity.--
                    (A) In general.--Each site shall be operated by a 
                single eligible operating entity under the entity's 
                nursing home license and provider certification, with 
                such entity to be responsible for management, 
                administration, and oversight of all small-house 
                nursing care homes within the site.
                    (B) Entities.--For purposes of this Act, an 
                eligible operating entity shall be--
                            (i) a skilled nursing facility (as defined 
                        in section 1819(a) of the Social Security Act 
                        (42 U.S.C. 1395i-3(a)));
                            (ii) a nursing facility (as defined in 
                        section 1919(a) of the Social Security Act (42 
                        U.S.C. 1396r(a))); or
                            (iii) an entity that has applied for 
                        certification pursuant to Federal, State, and 
                        local requirements for operation of a skilled 
                        nursing facility or nursing facility, provided 
                        that--
                                    (I) the proposal submitted by the 
                                entity pursuant to section 5(b) 
                                includes a plan for certification that 
                                has been determined by the technical 
                                assistance provider to be feasible and 
                                likely to result in certification by 
                                the State; and
                                    (II) the entity receives such 
                                certification not later than 24 months 
                                after selection by the technical 
                                assistance provider (as described in 
                                section 5(b)).
                    (C) Relationship to nursing care homes within 
                site.--A facility that has been designated as the 
                eligible operating entity--
                            (i) shall not be considered to be small-
                        house nursing care home for purposes of site 
                        and location requirements under this section; 
                        and
                            (ii) shall not be subject to requirements 
                        for small-house nursing care homes under 
                        section 3.
            (2) Site.--
                    (A) In general.--A site shall consist of--
                            (i) not less than 2 locations (as described 
                        in paragraph (3)); and
                            (ii) not less than a total of 4 small-house 
                        nursing care homes (as described in section 3) 
                        and not greater than a total of--
                                    (I) in rural areas (or a site that 
                                encompasses a rural area), 12 small-
                                house nursing care homes; or
                                    (II) in urban or suburban areas, 24 
                                small-house nursing care homes.
                    (B) Distances between locations within a site.--
                Distances between locations within a site may vary 
                based upon market demand and availability, with maximum 
                distances between locations to be established by the 
                eligible operating entity based upon the ability of 
                such entity to--
                            (i) deliver required services and 
                        supervision in a timely and appropriate manner; 
                        and
                            (ii) subject to subsection (f), meet all 
                        applicable statutory and regulatory 
                        requirements for operation of a nursing home.
            (3) Location.--
                    (A) In general.--Each location shall consist of not 
                greater than 2 small-house nursing care homes.
                    (B) Adjoining parcels.--A location shall--
                            (i) consist of a single parcel of land or 
                        multiple adjoining parcels of land; and
                            (ii) be separate from any other location 
                        and operate on a non-adjoining parcel of land 
                        from such location.
    (d) Continuation of Treatment as Single Provider.--The Secretary 
shall develop a process to allow a site, following the 5-year period 
for the CINCH demonstration program, to continue operation through a 
single operating entity and receive certification as a single provider 
for purposes of Medicare and Medicaid, including provisions to permit 
such continuation following a change in ownership of a participating 
small-house nursing care home.
    (e) Priority for Certification of Compliance.--For purposes of 
certifying compliance of nursing homes with Federal participation 
requirements under Medicare and Medicaid, the Secretary shall give 
priority to the review and certification of any nursing homes 
participating in the CINCH demonstration program.
    (f) Waiver Authority.--The Secretary may waive such requirements of 
titles XI, XVIII, and XIX of the Social Security Act as may be 
necessary to carry out the CINCH demonstration program and shall 
develop a process that permits sites to be certified and reimbursed 
under Medicare and Medicaid.

SEC. 5. SELECTION.

    (a) Technical Assistance Provider.--
            (1) In general.--Not later than 90 days after the date of 
        enactment of this Act, the Secretary, through a request for 
        proposal process, shall select a technical assistance provider 
        that shall be responsible for--
                    (A) selecting, assisting, and evaluating the 
                performance of eligible operating entities (as 
                described under subsection (b)); and
                    (B) ensuring that small-house nursing care homes 
                satisfy the requirements described in section 3.
            (2) Minimum requirements.--In selecting the technical 
        assistance provider, the Secretary shall ensure that such 
        organization--
                    (A) is a national not-for-profit organization that 
                is in good standing;
                    (B) has a consistent, clearly articulated, and 
                research-based model for operation of small-house 
                nursing care homes;
                    (C) has not less than 10 years of experience in 
                providing development, operation, regulatory, policy, 
                and financial consulting services to clients or 
                partners seeking to innovate the provision of long-term 
                care;
                    (D) has demonstrated a successful process and 
                record (for not less than 4 years) for selection and 
                assistance of multiple organizations in implementation 
                of a small-house nursing care home model, including 
                development, operations, and staff training;
                    (E) has established curricula for training of 
                leadership, clinical, and direct care staff;
                    (F) has demonstrated capacity, through its own 
                resources and consultants, to--
                            (i) collect MDS information and financial 
                        data from eligible operating entities; and
                            (ii) benchmark and analyze such financial 
                        data on not less than a quarterly basis;
                    (G) has the ability to administer the CINCH 
                demonstration program without additional funding from 
                Federal, State, or local governmental sources;
                    (H) agrees to provide technical assistance services 
                to eligible operating entities for a fee that is not 
                greater than its usual and customary fee for such 
                services; and
                    (I) agrees to maintain a provider network for 
                small-house nursing care homes participating in the 
                CINCH demonstration program for a fee that is not 
                greater than its usual and customary fee for such 
                services.
            (3) Preferences.--In selecting the technical assistance 
        provider, the Secretary shall give preference to an 
        organization that has demonstrated experience in related 
        business activities, including community-based care models, 
        health care financing, and demonstration programs.
    (b) Eligible Operating Entity.--
            (1) In general.--Selection of eligible operating entities 
        shall be determined by the technical assistance provider 
        through a request for proposal process on a continual basis.
            (2) Minimum requirements.--An eligible operating entity 
        seeking to participate in the CINCH demonstration program shall 
        be required to--
                    (A) commit to maintaining the small-house nursing 
                care home requirements described under section 3 and 
                permit the technical assistance provider to conduct 
                periodic evaluations to ensure adherence to such 
                requirements;
                    (B) maintain membership in a small-house nursing 
                care home provider network that is maintained by the 
                technical assistance provider; and
                    (C) subject to paragraph (3)(B), ensure that not 
                less 30 percent of the total capacity developed under 
                the CINCH demonstration program within the site, based 
                on the annual average for such site, is provided to 
                residents that are receiving nursing home benefits 
                under Medicaid, with any remaining capacity to be made 
                available to any individual seeking nursing home 
                services (including individuals eligible for Medicare, 
                privately insured individuals, or individuals paying 
                for their own care).
            (3) Additional considerations.--For purposes of selecting 
        eligible operating entities to participate in the CINCH 
        demonstration project, the technical assistance provider shall 
        take into consideration--
                    (A) the level and extent of services that will be 
                provided to residents by each small-house nursing care 
                home within the site, including whether such services 
                are sufficient to respond to the changing needs of 
                residents as they advance in age and thereby permit 
                them to continue to reside in the home; and
                    (B) whether an entity commits to a percentage of 
                total capacity within the site to residents that are 
                receiving nursing home benefits under Medicaid that is 
                higher than the minimum percentage of total capacity 
                described in paragraph (2)(C).

SEC. 6. NO ADDITIONAL PAYMENT.

    The technical assistance provider, as well as any eligible 
operating entities and participating small-house nursing care homes, 
shall not receive any additional payment or reimbursement under 
Medicare or Medicaid based upon their participation in the CINCH 
demonstration program.

SEC. 7. EVALUATION AND REPORT.

    (a) In General.--Not later than 4 years after the date of enactment 
of this Act, the technical assistance provider shall evaluate the 
performance of each of the sites participating under the CINCH 
demonstration program and shall submit to the Secretary a report 
containing the results of such evaluation.
    (b) Evaluation Requirements.--The evaluation described in 
subsection (a) shall include an analysis of--
            (1) not less than 12 months of MDS information and 
        financial data from at least 10 small-house nursing care homes; 
        and
            (2) results from focus groups or surveys regarding health 
        outcomes for residents and program costs.
    (c) Testing and Expansion Through the Center for Medicare and 
Medicaid Innovation.--Not later than 6 months after receiving the 
report submitted under subsection (a), the Secretary shall, through the 
Center for Medicare and Medicaid Innovation established under section 
1115A of the Social Security Act (42 U.S.C. 1315A), perform an 
evaluation (as described in subsection (b)(4) of such section) of the 
CINCH demonstration program and, pursuant to the requirements under 
subsection (c) of such section, determine whether an expansion of the 
CINCH demonstration program is appropriate.
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