[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 8100 Introduced in House (IH)]
<DOC>
119th CONGRESS
2d Session
H. R. 8100
To amend titles XI, XVIII, and XIX of the Social Security Act with
respect to minimum staffing levels in skilled nursing facilities and
nursing facilities under the Medicare and Medicaid programs.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
March 26, 2026
Mr. Doggett (for himself and Ms. Schakowsky) 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 XI, XVIII, and XIX of the Social Security Act with
respect to minimum staffing levels in skilled nursing facilities and
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 ``Safe Staffing Saves Lives Act''.
SEC. 2. MINIMUM STAFFING LEVELS IN NURSING FACILITIES AND SKILLED
NURSING FACILITIES.
(a) Establishing Minimum Staffing Levels for Registered Nurses in
Nursing Facilities and Skilled Nursing Facilities.--
(1) Medicare.--
(A) In general.--Section 1819(b)(4) of the Social
Security Act (42 U.S.C. 1395i-3(b)(4)) is amended--
(i) in subparagraph (C)--
(I) in the subparagraph heading, by
inserting ``before 2029'' after
``Required nursing care''; and
(II) in clause (i), by striking
``Except as provided in clause (ii)''
and inserting ``With respect to skilled
nursing facility services furnished
before January 1, 2029, except as
provided in clause (ii)''; and
(ii) by adding at the end the following new
subparagraph:
``(D) Required nursing care beginning in 2029.--
``(i) In general.--Subject to clause (iii),
beginning January 1, 2029, a skilled nursing
facility--
``(I) must provide 24-hour licensed
nursing services which are sufficient
to meet the nursing needs of its
residents;
``(II) must provide for minimum
nurse staffing levels with respect to
each day;
``(III) must ensure that, in
carrying out subclauses (I) and (II), a
total minimum of 4.1 hours of nursing
care is provided per resident per day,
with--
``(aa) 1.3 hours of care of
such total minimum consisting
of licensed nursing services,
with 0.75 hours of such care
provided by a registered
professional nurse and 0.55
hours of such care provided by
a licensed practical nurse; and
``(bb) 2.8 hours of care of
such total minimum provided by
a nurse aide (as defined in
paragraph (5)(F)); and
``(IV) must ensure that a
registered professional nurse is onsite
and available to furnish licensed
nursing services 24 hours a day, 7 days
a week.
``(ii) Secretarial authority to establish
higher minimum nurse staffing levels.--The
Secretary may establish and require skilled
nursing facilities to provide for minimum nurse
staffing levels that are higher than the levels
required under this subparagraph.
``(iii) Waiver.--
``(I) In general.--Subject to the
succeeding provisions of this clause,
the Secretary may waive the
requirements under clause (i) (and such
additional requirements as may be
established under clause (ii)) with
respect to a skilled nursing facility
for a period of not more than 180 days
if--
``(aa) the facility
demonstrates to the
satisfaction of the Secretary
that the facility cannot
reasonably comply with such
requirements;
``(bb) the facility
provides to the Secretary such
information as the Secretary
determines necessary to support
a determination under item
(aa), which shall include
information with respect to--
``(AA) workforce
and wage data for the
area in which the
facility is located;
``(BB) additional
employee benefits
offered by the
facility;
``(CC) the annual
rate of turnover with
respect to nursing
staff at the facility,
disaggregated by
category of staff; and
``(DD) the
facility's demonstrated
commitment to hiring
nursing staff; and
``(cc) the Secretary
provides notice of the waiver
to the State long-term care
ombudsman (established under
section 307(a)(12) of the Older
Americans Act of 1965) and the
protection and advocacy system
in the State for the mentally
ill and the mentally retarded.
``(II) Ineligibility.--The
Secretary may not grant a waiver under
this clause to a skilled nursing
facility that--
``(aa) has been identified
under the special focus
facility program under
subsection (f)(8) as having
substantially failed to meet an
applicable requirement of this
Act; or
``(bb) during the 1-year
period preceding a request for
such a waiver, was found to
have deficiencies that--
``(AA) resulted in
harm to a resident; or
``(BB) immediately
jeopardized the health
or safety of its
residents.
``(III) Limitations.--A skilled
nursing facility may not receive more
than 2 consecutive waivers under this
clause.
``(iv) Rule of construction regarding state
authority to establish higher minimum nurse
staffing levels.--Nothing in this subparagraph
may be construed as preventing a State from
establishing or requiring skilled nursing
facilities in the State to provide for minimum
nurse staffing levels that are higher than the
levels required under this subparagraph.''.
(B) Enforcement.--
(i) Increased survey frequency.--Section
1819(g)(2)(A)(iii) of the Social Security Act
(42 U.S.C. 1395i-3(g)(2)(A)(iii)) is amended--
(I) in subclause (I), by striking
``Each'' and inserting ``Subject to
subclause (III), each''; and
(II) by adding at the end the
following new subclause:
``(III) Staffing level surveys.--
Beginning January 1, 2029, in the case
of a skilled nursing facility that is
found not to meet the minimum staffing
requirements of subsection (b)(4)(D)
(including such a facility that has in
effect a waiver of such requirements
under clause (iii) of such subsection),
such facility shall be subject to a
standard survey not later than 3 months
after the date of the previous standard
survey conducted under this
subparagraph.''.
(ii) Prohibition on admission of new
residents; audits.--Section 1819(h) of the
Social Security Act (42 U.S.C. 1395i-3(h)) is
amended--
(I) in paragraph (1), by striking
``If a State finds, on the basis of a
standard'' and inserting ``Subject to
paragraph (7), if a State finds, on the
basis of a standard'';
(II) in paragraph (2), by striking
``With respect to'' and inserting
``Subject to paragraph (7), with
respect to''; and
(III) by adding at the end the
following new paragraph:
``(7) Special rule with respect to minimum nurse staffing
requirements.--
``(A) In general.--Beginning January 1, 2029, if a
State finds, on the basis of a standard, extended, or
partial extended survey under subsection (g)(2) or
otherwise, that a skilled nursing facility does not
meet the minimum staffing requirements of subsection
(b)(4)(D) (without regard to whether such facility has
in effect a waiver of such requirements under clause
(iii) of such subsection), the State shall recommend to
the Secretary that the Secretary take such actions as
described in subparagraph (B).
``(B) Secretarial authority.--Beginning January 1,
2029, with respect to any skilled nursing facility in a
State, if the Secretary finds, or pursuant to a
recommendation of the State under subparagraph (A)
finds, that a skilled nursing facility does not meet
the minimum staffing requirements of subsection
(b)(4)(D) (without regard to whether such facility has
in effect a waiver of such requirements under clause
(iii) of such subsection), the Secretary shall deny any
further payments under this title with respect to any
individuals entitled to benefits under this title
admitted to the facility for the period beginning on
the effective date of the finding and ending on the
later of--
``(i) the date that is 180 days after such
effective date; or
``(ii) the date on which the Secretary
determines that the facility has come into
compliance with such minimum staffing
requirements.
``(C) Relationship to other enforcement
mechanisms.--The remedies provided under this paragraph
are in addition to those otherwise available under this
subsection and shall not be construed as limiting such
other remedies.''.
(iii) Ineligibility for snf vbp program.--
Section 1888(h)(1)(C) of the Social Security
Act (42 U.S.C. 1395yy(h)(1)(C)) is amended--
(I) by redesignating clauses (i)
and (ii) as subclauses (I) and (II),
respectively, and adjusting the margins
accordingly;
(II) by striking ``With respect''
and inserting the following:
``(i) In general.--With respect''; and
(III) by adding at the end the
following new clause:
``(ii) Exclusion of facilities out of
compliance with minimum staffing standards.--
With respect to payments for services furnished
on or after January 1, 2029, this subsection
shall not apply to a facility that does not
meet the minimum staffing requirements of
subsection (b)(4)(D) (including such a facility
that has in effect a waiver of such
requirements under clause (iii) of such
subsection).''.
(C) Application to transfer and discharge rights.--
Section 1819(c)(2)(A) of the Social Security Act (42
U.S.C. 1395i-3(c)(2)(A)) is amended by adding at the
end of the flush-left text the following new sentence:
``Beginning January 1, 2029, a skilled nursing facility
may not transfer or discharge a resident solely for
purposes of meeting the minimum staffing requirements
under subsection (b)(4)(D).''.
(D) Notice of noncompliance to residents and
guardians.--
(i) In general.--Section 1819(c) of the
Social Security Act (42 U.S.C. 1395i-3(c)) is
amended by adding at the end the following new
paragraph:
``(7) Notice in the case of noncompliance with minimum
staffing standards.--Beginning January 1, 2029, in the case of
a skilled nursing facility that does not meet the minimum
staffing requirements of subsection (b)(4)(D) (including such a
facility that has in effect a waiver of such requirements under
clause (iii) of such subsection), such facility shall--
``(A) prominently display at the entrance to the
facility a notice that such facility does not meet such
standards (and has in effect such a waiver, if
applicable); and
``(B) provide each resident of the facility (or,
where appropriate, the guardians or legal
representatives of such residents) and members of their
immediate families with a written copy of such
notice.''.
(ii) Nursing home compare website.--Section
1819(i)(1)(A)(i) of the Social Security Act (42
U.S.C. 1395i-3(i)(1)(A)(i)) is amended by
inserting ``(and, beginning January 1, 2029,
information on whether the facility meets the
minimum staffing requirements of subsection
(b)(4)(D) (or has in effect a waiver of such
requirements under clause (iii) of such
subsection)'' after ``staffing turnover and
tenure''.
(E) Conforming amendment.--Section
1819(f)(2)(B)(iii)(I)(a) of the Social Security Act (42
U.S.C. 1395i-3(f)(2)(B)(iii)(I)(a)) is amended by
inserting ``or subsection (b)(4)(D)(iii)'' after
``subsection (b)(4)(C)(ii)(II)''.
(2) Medicaid.--
(A) In general.--Section 1919(b)(4) of the Social
Security Act (42 U.S.C. 1396r(b)(4)) is amended--
(i) in subparagraph (C)(i)--
(I) in the clause heading, by
inserting ``before 2029'' after
``General requirements''; and
(II) in the matter preceding
subclause (I), by inserting ``and
before January 1, 2029,'' after ``With
respect to nursing facility services
provided on or after October 1,
1990,''; and
(ii) by adding at the end the following new
subparagraph:
``(D) General requirements beginning in 2029.--
``(i) In general.--Subject to clause (iii),
beginning January 1, 2029, a nursing facility--
``(I) must provide 24-hour licensed
nursing services which are sufficient
to meet the nursing needs of its
residents;
``(II) must provide for minimum
nurse staffing levels with respect to
each day;
``(III) must ensure that, in
carrying out subclauses (I) and (II), a
total minimum of 4.1 hours of nursing
care is provided per resident per day,
with--
``(aa) 1.3 hours of care of
such total minimum consisting
of licensed nursing services,
with 0.75 hours of such care
provided by a registered
professional nurse and 0.55
hours of such care provided by
a licensed practical nurse; and
``(bb) 2.8 hours of care of
such total minimum provided by
a nurse aide (as defined in
paragraph (5)(F)); and
``(IV) must ensure that a
registered professional nurse is onsite
and available to furnish licensed
nursing services 24 hours a day, 7 days
a week.
``(ii) Secretarial authority to establish
higher minimum nurse staffing levels.--The
Secretary may establish and require nursing
facilities to provide for minimum nurse
staffing levels that are higher than the levels
required under this subparagraph.
``(iii) Waiver.--
``(I) In general.--Subject to the
succeeding provisions of this clause, a
State may waive the requirements under
clause (i) (and such additional
requirements as may be established
under clause (ii)) with respect to a
nursing facility for a period of not
more than 180 days if--
``(aa) the facility
demonstrates to the
satisfaction of the State that
the facility cannot reasonably
comply with such requirements;
``(bb) the facility
provides to the State such
information as the State
determines necessary to support
a determination under item
(aa), which shall include
information with respect to--
``(AA) workforce
and wage data for the
area in which the
facility is located;
``(BB) additional
employee benefits
offered by the
facility;
``(CC) the annual
rate of turnover with
respect to nursing
staff at the facility,
disaggregated by
category of staff; and
``(DD) the
facility's demonstrated
commitment to hiring
nursing staff; and
``(cc) the State agency
granting a waiver of such
requirements provides notice of
the waiver to the State long-
term care ombudsman
(established under section
307(a)(12) of the Older
Americans Act of 1965) and the
protection and advocacy system
in the State for the mentally
ill and the mentally retarded.
A waiver under this clause shall be
subject to the review of the Secretary
and subject to clause (iv) shall be
accepted by the Secretary for purposes
of this title to the same extent as is
the State's certification of the
facility. In granting or renewing a
waiver, a State may require the
facility to use other qualified,
licensed personnel.
``(II) Ineligibility.--The State
may not grant a waiver under this
clause to a skilled nursing facility
that--
``(aa) has been identified
under the special focus
facility program under
subsection (f)(10) as having
substantially failed to meet
applicable requirements of this
Act; or
``(bb) during the 1-year
period preceding a request for
such a waiver, was found to
have deficiencies that--
``(AA) resulted in
harm to a resident; or
``(BB) immediately
jeopardized the health
or safety of its
residents.
``(III) Limitations.--A nursing
facility may not receive more than 2
consecutive waivers under this clause.
``(iv) Assumption of waiver authority by
secretary.--If the Secretary determines that a
State has shown a clear pattern and practice of
allowing waivers in the absence of diligent
efforts by facilities to meet the staffing
requirements, the Secretary shall assume and
exercise the authority of the State to grant
waivers.
``(v) Rule of construction regarding state
authority to establish higher minimum nurse
staffing levels.--Nothing in this subparagraph
may be construed as preventing a State from
establishing or requiring skilled nursing
facilities in the State to provide for minimum
nurse staffing levels that are higher than the
levels required under this subparagraph.''.
(B) Enforcement.--
(i) Increased survey frequency.--Section
1919(g)(2)(A)(iii) of the Social Security Act
(42 U.S.C. 1396r(g)(2)(A)(iii)) is amended--
(I) in subclause (I), by striking
``Each'' and inserting ``Subject to
subclause (III), each''; and
(II) by adding at the end the
following new subclause:
``(III) Staffing level surveys.--
Beginning January 1, 2029, in the case
of a nursing facility that is found not
to meet the minimum staffing
requirements of subsection (b)(4)(D)
(including such a facility that has in
effect a waiver of such requirements
under clause (iii) of such subsection),
such facility shall be subject to a
standard survey not later than 3 months
after the date of the previous standard
survey conducted under this
subparagraph.''.
(ii) Prohibition on admission of new
resident; audits.--Section 1919(h) of the
Social Security Act (42 U.S.C. 1396r(h)) is
amended--
(I) in paragraph (1), by striking
``If a State finds, on the basis of a
standard'' and inserting ``Subject to
paragraph (10), if a State finds, on
the basis of a standard'';
(II) in paragraph (2)--
(aa) in subparagraph (C),
by striking ``If a nursing
facility'' and inserting
``Subject to paragraph (10), if
a nursing facility''; and
(bb) in subparagraph (D),
by striking ``In the case of''
and inserting ``Subject to
paragraph (10), in the case
of'';
(III) in paragraph (3)--
(aa) in subparagraph (A),
by inserting before the period
the following: ``and the
remedies described in paragraph
(10)(B)''; and
(bb) in subparagraph (B),
by striking ``With respect to''
and inserting ``Subject to
paragraph (10), with respect
to''; and
(IV) by adding at the end the
following new paragraph:
``(10) Special rule with respect to minimum nurse staffing
requirements.--
``(A) In general.--Beginning January 1, 2029, if a
State finds, on the basis of a standard, extended, or
partial extended survey under subsection (g)(2) or
otherwise, that a nursing facility does not meet the
minimum staffing requirements of subsection (b)(4)(D)
(without regard to whether such facility has in effect
a waiver of such requirements under clause (iii) of
such subsection), the State shall--
``(i) deny any further payments under the
State plan with respect to all individuals
enrolled under such plan who are admitted to
the facility after the effective date of the
finding; and
``(ii) recommend to the Secretary that the
Secretary take such actions as described in
subparagraph (B).
``(B) Secretarial authority.--Beginning January 1,
2029, with respect to any nursing facility in a State
other than a State nursing facility, if the Secretary
finds, or pursuant to a recommendation of the State
under subparagraph (A) finds, that a skilled nursing
facility does not meet the minimum staffing
requirements of subsection (b)(4)(D) (without regard to
whether such facility has in effect a waiver of such
requirements under clause (iii) of such subsection),
the Secretary shall deny any further payments to the
State for medical assistance furnished by the facility
to any individual admitted to the facility for the
period beginning on the effective date of the finding
and ending on the later of--
``(i) the date that is 180 days after such
effective date; or
``(ii) the date on which the Secretary
determines that the facility has come into
compliance with such minimum staffing
requirements.
``(C) Relationship to other enforcement
mechanisms.--The remedies provided under this paragraph
are in addition to those otherwise available under this
subsection and shall not be construed as limiting such
other remedies.''.
(iii) Ineligibility for certain state
directed payments.--The Secretary of Health and
Human Services shall revise section 438.6(c)(2)
of title 42, Code of Federal Regulations (or a
successor regulation), such that, beginning
January 1, 2029, no State directed payment
specified in such section may be made for
nursing facility services furnished by a
facility that does not meet the minimum
staffing requirements of subparagraph (D) of
section 1919(b)(4) of the Social Security Act
(42 U.S.C. 1396r(b)(4)), as added by
subparagraph (A) (including such a facility
that has in effect a waiver of such
requirements under clause (iii) of such
subparagraph).
(iv) Application to transfer and discharge
rights.--Section 1919(c)(2)(A) of the Social
Security Act (42 U.S.C. 1396r(c)(2)(A)) is
amended by adding at the end of the flush-left
text the following new sentence: ``Beginning
January 1, 2029, a nursing facility may not
transfer or discharge a resident solely for
purposes of meeting the minimum staffing
requirements under subsection (b)(4)(D).''.
(v) Notice of noncompliance to residents
and guardians.--
(I) In general.--Section 1919(c) of
the Social Security Act (42 U.S.C.
1396r(c)) is amended by adding at the
end the following new paragraph:
``(9) Notice in the case of noncompliance with minimum
staffing standards.--Beginning January 1, 2029, in the case of
a nursing facility that does not meet the minimum staffing
requirements of subsection (b)(4)(D) (including such a facility
that has in effect a waiver of such requirements under clause
(iii) of such subsection), such facility shall--
``(A) prominently display at the entrance to the
facility a notice that such facility does not meet such
standards (and has in effect such a waiver, if
applicable); and
``(B) provide each resident of the facility (or,
where appropriate, the guardians or legal
representatives of such residents) and members of their
immediate families with a written copy of such
notice.''.
(II) Nursing home compare
website.--Section 1919(i)(1)(A)(i) of
the Social Security Act (42 U.S.C.
1396r(i)(1)(A)(i)) is amended by
inserting ``(and, beginning January 1,
2029, information on whether the
facility meets the minimum staffing
requirements of subsection (b)(4)(D)
(or has in effect a waiver of such
requirements under clause (iii) of such
subsection)'' after ``staffing turnover
and tenure''.
(C) Conforming amendments.--
(i) Item (a) of section
1919(f)(2)(B)(iii)(I) of the Social Security
Act (42 U.S.C. 1396r(f)(2)(B)(iii)(I)) is
amended by inserting ``or subsection
(b)(4)(D)(iii)'' after ``subsection
(b)(4)(C)(ii)''.
(ii) Paragraph (9) of section 1919(f) of
the Social Security Act (42 U.S.C. 1396r(f)) is
amended by inserting ``or subsection
(b)(4)(D)(iii)'' after ``subsection
(b)(4)(C)(ii)''.
(b) Inclusion of Timestamp on Facility Staffing Data.--Section
1128I(g) of the Social Security Act (42 U.S.C. 1320a-7j(g)) is
amended--
(1) in paragraph (3), by striking ``and'' at the end;
(2) in paragraph (4), by striking the period at the end and
inserting ``; and''; and
(3) by inserting after paragraph (4) the following new
paragraph:
``(5) beginning January 1, 2027, include time-stamped
information on the hours worked per day by each certified
employee in each category of certified employees referenced in
paragraph (1).''.
(c) Reports.--Section 1128I of the Social Security Act (42 U.S.C.
1320a-7j) is amended by adding at the end the following new subsection:
``(i) Reports on Facility Staffing Levels.--Not later than January
1, 2034, and every 5 years thereafter, the Secretary of Health and
Human Services shall submit to Congress a report on the minimum nurse
staffing levels required under sections 1819(b)(4)(D) and
1919(b)(4)(D). Each such report shall include--
``(1) an analysis of the impact of such minimum nurse
staffing levels on--
``(A) resident safety;
``(B) quality of care;
``(C) the rate of deficiency citations received by
facilities; and
``(D) wages, benefits, and employment retention of
nurse staff; and
``(2) recommendations as to whether such minimum nurse
staffing levels should be adjusted.''.
<all>