[Congressional Record Volume 146, Number 124 (Friday, October 6, 2000)]
[Senate]
[Pages S10083-S10088]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. GRASSLEY (for himself, Mr. Breaux, and Mr. Reed):
  S. 3177. 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; to the Committee on Finance.


               NURSING HOME STAFF IMPROVEMENT ACT OF 2000

  Mr. GRASSLEY. Mr. President, I am pleased to have the support of 
Senator Breaux in introducing The Nursing Home Staff Improvement Act of 
2000. This is an important piece of legislation for the 1.6 million 
frail elderly Americans who reside in nursing homes across the nation.
  A recently released and long overdue report from the Health Care 
Financing

[[Page S10086]]

Administration was the immediate impetus for our bill. This report was 
first mandated by Congress in 1990. It took the Department of Health 
and Human Services 10 years to complete Part I of the report. It will 
take almost another year to finish it. The first part of the study 
documented, to just about everyone's satisfaction, severe staffing 
shortages, severe staffing shortages in our nation's nursing homes. 
While we are waiting for the agency to complete the second and final 
part of the report, Senate Breaux and I want to begin to address the 
staffing crisis in long-term care. Therefore, we are introducing this 
legislation today.
  We have a long way to go in meeting the staffing needs of elderly 
nursing home residents. The bill we are introducing today is not the 
answer to the problem. It is only a first step. Yet, it is an extremely 
important step that Congress should take.
  Before describing the bill Senator Breaux and I are introducing 
today, I'd like to take a couple of minutes to go over the history of 
our committee's work on nursing home quality of care and HCFA oversight 
of the Nursing Home Reform Act of 1987. It's important for me to 
emphasize the scope and depth of the problem in order to give my fellow 
Senators an appreciation of the context out of which this legislation 
developed.
  In the fall of 1997, serious allegations were brought to my attention 
about the quality of care provided in California nursing homes. These 
allegations claimed that thousands of California nursing home residents 
had suffered and met with untimely and unnecessary deaths due to 
malnutrition, dehydration, decubitus ulcers, and urinary tract 
infections.
  In an effort to respond to these allegations, I asked the General 
Accounting Office [GAO] to conduct a thorough review of them and, more 
generally, of the quality of care in California nursing homes.
  This review culminated in a 2-day hearing held on July 27-28, 1998, 
entitled ``Betrayal: The Quality of Care in California Nursing Homes.'' 
At this hearing, the GAO released its report titled ``California 
Nursing Homes: Care Problems Persist Despite Federal and State 
Oversight.'' The findings of this report were explosive and disturbing, 
illustrating that residents in far too many California nursing homes 
were threatened by seriously substandard care.
  One week prior to this hearing, the Clinton administration announced 
a broad set of new nursing home initiatives to improve enforcement of 
the Nursing Home Reform Act and, hence, the quality of care in nursing 
facilities. The administration was acting in response to the impending 
release of the GAO's study before the scheduled Aging Committee 
hearing. It acted also in response to a congressionally mandated report 
by the Department of Health and Human Services on nursing home 
oversight that was completed just before the hearing. The Department's 
report uncovered weaknesses on the part of the federal government in 
its oversight of nursing home quality of care. As the Federal agency 
with regulatory oversight responsibility over our Nation's nursing 
homes, the Health Care Financing Administration [HCFA] is responsible 
for monitoring the compliance of nursing home facilities in meeting the 
requirements of the Nursing Home Reform Act. For facilities found to be 
noncompliant, HCFA is responsible for seeing that remedies or sanctions 
are imposed until the situation is corrected. The administration's 
report found shortcomings in HCFA's enforcement of the Nursing Home 
Reform Act of 1987. The agency's report was really a kind of self-
indictment. Up to that point, the agency had failed in its 
responsibility to protect nursing home residents.

  As part of its multistep initiative, the administration called for 
improvements in nursing home inspections, better and more timely 
enforcement against nursing homes that repeatedly violate safety rules, 
and more attention to quality of care for nursing home residents 
through prevention of bed sores, malnutrition and dehydration. HCFA was 
given the responsibility for carrying out this initiative. Under my 
chairmanship, the Senate Special Committee on Aging has taken an active 
role in overseeing the implementation of the President's nursing home 
initiative led by the Administrator of HCFA. At regular hearings and 
forums, 10 to be specific, I have heard from family members, health 
care professionals and other long-term care experts about the progress 
and obstacles in achieving improved nursing home quality of care.
  Anecdotally, we have heard from the very beginning of our work on 
nursing home quality of care that understaffing is a root cause of many 
of the problems facing nursing home residents. Because we desperately 
needed a more systematic, research-based analysis of this understaffing 
problem, I had persistently urged HCFA to finish the long delayed 
staffing report I mentioned earlier.
  On July 27, 2000, Part I of the report, entitled ``Appropriateness of 
Minimum Staffing Ratios in Nursing Homes'' was done, and our committee 
held a hearing to take testimony on it. The report and the hearing 
presented groundbreaking new information on nursing facility staffing. 
It was the first time that understaffing, and the consequences of 
understaffing, were described by a scientifically sound government 
report. Although a Part II of the report will be required to completely 
validate the findings of Part I and to analyze a number of other 
questions raised by Part I, the report showed for the first time what 
family members and resident advocates had been saying for years: that 
the majority of nursing homes in our country are dramatically 
understaffed. Specifically, the report concluded that more than half of 
nursing facilities around the country employ too few nurses and nurse 
aides to provide adequate care to residents.
  As a result of these report findings, I began working on legislation 
to address the serious problems of understaffing. I started by seeking 
input from interested parties, including the Administration, nursing 
home providers, health care professionals, and resident advocates. I 
finalized my proposal right around the same time the President 
announced the administration's initiative in this area. The two 
proposals are similar in their goal to start addressing the problems of 
understaffing in nursing facilities.
  As I said earlier, the impetus for my bill was the Report to Congress 
on the ``Appropriateness of Minimum Nurse Staffing Ratios in Nursing 
Homes''. The major conclusions of the report are outlined in the 
Findings section of our bill. The report found that 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. The 
findings also showed that 2.9 nurse aide hours per resident day are 
necessary for a nurse aide to complete core resident care tasks, 
although, because of the very conservative estimates used in this part 
of the study, 2.9 hours probably significantly understates the staffing 
levels necessary for a nurse aide to complete these core tasks. Part I 
of the report also indicated that Part II will analyze and report on 
minimum staffing levels according to a facility's resident acuity 
level. I urge Congress and the Administration to be careful in 
accepting either the 2.0 or 2.9 nurse aide hours per resident day as a 
minimum goal for nursing facilities until these results are validated 
and case-mix is included in the equation. It is reasonable to expect 
that staffing requirements will be substantially higher for facilities 
that have residents with higher acuity.
  Our bill calls for the completion of phase two of the study. It 
requires the Secretary to complete the report not later than July 1, 
2001. It adds to the original authority a requirement that the study 
undertake several tasks that Part I of the report stated would be done 
in the second phase. Among other things, these tasks include a 
requirement that the case mix analysis of Part I of the report be 
further refined and related to appropriate minimum staffing levels. It 
also adds to the original authority a requirement that the report 
analyze ``optimal minimum'' caregiver to resident levels and ``optimal 
minimum'' supervisor to caregiver levels of skilled nursing facilities 
participating in the Medicare program and nursing facilities 
participating in the Medicaid program. We modified the original 
authority in this manner because we believed the public should know not 
just appropriate minimum

[[Page S10087]]

staffing levels, but also what more optimal staffing levels should be 
in nursing facilities.
  My bill requires that minimum staffing levels be developed and 
enforced within one year of the completion of the Report. It requires 
the Secretary to make recommendations regarding appropriate minimum 
caregiver to resident levels and minimum supervisor to caregiver levels 
for skilled nursing facilities participating in the Medicare program 
and nursing facilities participating in the Medicaid program. The 
Secretary further shall require through the administrative rulemaking 
process compliance with appropriate minimum staffing levels as a 
condition for such facilities to receive payment under those programs. 
The Secretary would be required to promulgate a final rule not later 
than one year after completion of the report.
  The bill requires that the Secretary establish appropriate minimum 
staffing levels because we believed that a regulatory requirement 
should establish those staffing levels that will assure that residents 
receive the quality of care they have a right to receive under the 
terms of the Nursing Home Reform Act of 1987. We assume that the 
resident case mix of a facility will have an effect on the appropriate 
minimum staffing levels of the facility.
  In order to help States prepare for the minimum staffing levels that 
the Secretary will promulgate by July 1, 2002, my bill establishes a 
competitive state grant program. The purpose of the grant program will 
be to improve staffing levels in nursing facilities in order to improve 
the quality of care to residents of such facilities. A state that 
secures such a grant may provide technical or financial support to 
nursing facilities, labor organizations, nonprofit organizations, 
community colleges, or other organizations approved by the Secretary. 
Such support from the state shall be used for projects which will help 
to increase or improve recruitment and retention of direct care nursing 
staff. Projects supported by a state must be consistent with the 
requirements of sections 1818 and 1919 of the Social Security Act. No 
funds may be made available to county or state-owned nursing 
facilities. Funds used under a grant to a state may only be used to 
supplement, not supplant, other funds that the state extends to carry 
out the activities that may be supported by this grant program. The 
Secretary shall evaluate this grant program and report to the Congress 
on her findings not later than six months after completion of the grant 
program. Authorized to be appropriated are $500,000,000 for each of 
fiscal years 2001 and 2002.

  My bill includes a requirement for reporting of accurate information 
on staffing. Skilled nursing facilities participating in the Medicare 
program and nursing facilities participating in the Medicaid program 
would be required to submit staffing information to the Secretary in a 
form and manner determined by the Secretary. Such information must be 
attested to as accurate by the reporting facility. The Secretary shall 
periodically post and update such information on the Nursing Home 
Compare web site. Skilled nursing facilities participating in the 
Medicare program and nursing facilities participating in the Medicaid 
program shall submit to the Secretary a classification of all residents 
of the facility according to the resident classification system 
required under current law. My understanding is that nursing facilities 
should have data on hand and in a form that would be required by the 
Secretary for reporting to the Department, and, thus, the 
administrative burden of this requirement should be minimal.
  My bill includes a requirement for posting of facility staffing 
information. Facilities participating in the Medicare and Medicaid 
program would be required to post daily for each nursing unit and each 
work shift the current number of licensed and unlicensed nursing staff 
directly responsible for resident care together with the number of 
residents per unit and shift.
  Throughout my work and oversight activity of nursing facility quality 
of care, I have made it a point to stress that there are many good 
nursing facilities. When a family is in need of a facility for a loved 
one, it is critically important that individuals shop around and gather 
information in order to find the best nursing home to meet the needs of 
their loved ones. The provision in my bill calling for additional 
reporting of staffing and facility posting of staffing data will help 
families which need to find a good facility for a loved one's 
placement. It should also eventually have an effect on the overall 
quality of care in nursing facilities as families search out and choose 
better facilities.
  The information collected by HCFA will help it improve and maintain 
its Nursing Home Compare web site. This is a database which contains 
information on every Medicare and Medicaid certified nursing home in 
the country. You can locate nursing homes in your area and find 
information about compliance with Medicare and Medicaid regulations 
based on the facility's most recent survey by state inspectors. 
Additionally, the web site contains useful phone numbers for survey 
agencies and long term care ombudsmen on the web site's ``Phone 
Directory'' page.
  In closing, I plan to continue my work to improve quality of care and 
quality of life for nursing home residents. In my position as Chairman 
of the Special Committee on Aging, I will continue to monitor the 
quality of care provided to our nation's nursing home residents. With 
the assistance of the GAO, I will continually assess and monitor the 
Health Care Financing Administration's progress and commitment to 
improving the quality of care in nursing homes.
  Mr. BREAUX. Mr. President, I rise today as ranking member of the 
Special Committee on Aging and am proud to inform you that after the 
culmination of years of investigation and attention to the relationship 
between nursing home staff levels and quality of care, today Senator 
Grassley--my colleague on the Committee--and I are introducing 
legislation on this important issue. Our ``Nursing Facility Staff 
Improvement Act of 2000'' would encourage increased quantities of staff 
but also would improve the quality of those caring for our loved ones 
in nursing homes.
  Chairman Grassley and I have been committed to ensuring that our 
seniors are getting the best quality care possible in our nation's 
nursing homes, and the Aging Committee has held numerous hearings 
regarding the best way to reach this goal. We have been working with 
HCFA to determine the best way to ensure state surveyors are 
appropriately monitoring the quality of care their residents receive. 
Additionally, we held a hearing to learn from industry representatives 
about the links between nursing home bankruptcies and quality care. And 
we have continually and consistently sent the message that we will 
remain involved and committed to improvement for as long as it takes.
  The bill we introduce today--the Nursing Facility Staff Improvement 
Act of 2000--is the result of bipartisan efforts to put something on 
the books that will not only provide real incentives for nursing home 
staff to strive to do their jobs well but will also be a huge step 
toward defining what optional nursing home care should entail. I 
commend President Clinton for building on the Aging Committee's 
findings and making this very important issue one of his priorities.
  More specifically, this bill will:
  Call for the Secretary of HHS to establish a competitive grant 
program to the states to increase or improve the recruitment and 
retention of direct care nursing staff. Provide for $1 billion over two 
years. Require that HCFA complete Phase II of their Nursing Home 
Staffing study and report back not later than July 1, 2001. Appropriate 
use of grant monies would include: establishing career ladders for 
nurse aides; improving nursing management; providing additional 
training programs for staff.
  In conclusion, it is exciting for me to put forth a piece of 
legislation that offers tangible incentives to current and future staff 
and also directly encourages appropriate nursing home care for our 
loved ones. This effort has truly been one of joint cooperation between 
my Republican colleague on the Aging Committee and myself and I am 
proud to introduce it to you today.
  Mr. REED. Mr. President, I rise today to join my colleague from Iowa, 
the Chairman of the Special Senate Committee on Aging, to introduce 
legislation that we hope will begin to address an immediate and 
critical labor

[[Page S10088]]

shortage facing nursing home facilities across the nation as well as 
the long term objective of establishing nursing home staffing 
thresholds.
  In late July, the Health Care Financing Administration, HCFA, 
released the first phase of its long awaited report on the feasibility 
and appropriateness of minimum nursing home staffing ratios. The 
initial phase of this report explored the relationship between staffing 
levels and quality of care. The HCFA study found a strong correlation 
between certain staffing thresholds and the quality of care provided to 
nursing home residents. The report also found that nursing homes are 
having great difficulty in recruiting and retaining qualified staff to 
work in their facilities. Clearly, we can and should be doing more to 
ensure that the care of our elderly and disabled is not being placed at 
risk.
  In my home state of Rhode Island, we have been dealing with a 
critical shortage in the number of Certified Nursing Assistants, CNAs, 
in particular. CNAs provide direct care in a skilled nursing setting to 
residents who need help with essential daily living tasks, such as 
dressing, feeding and bathing. A state task force comprised of long 
term care providers and nursing home consumer advocates found that over 
26,000 individuals were licensed as CNAs, but only 14,000 are currently 
working in the field. The task force also found that the turnover rate 
for CNAs rose to an unprecedented 82.6 percent in 1999.
  The two most important issues identified in the state report were 
wages and adequate staffing levels. In terms of wages, a person in my 
state can make more in starting salary as a hotel maid in Providence 
($9.50/hour) than they would as a licensed CNA ($7.69/hour). Those 
individuals who have dedicated their careers to caring for our most 
vulnerable citizens certainly deserve better and the legislation we are 
introducing today will help to restore respect and dignity to the 
caregiver profession.
  The Nursing Home Staff Improvement Act will address these problems in 
essentially two ways. First, the legislation requires the Secretary of 
Health and Human Services to complete the second phase of the nursing 
home staffing report by July 2001. The Secretary will then be called 
upon to use the findings and recommendations of the final report to 
develop appropriate caregiver to resident and supervisor to caregiver 
ratios for nursing facilities that participate in the Medicare and 
Medicaid programs. The second major component of the bill is the 
establishment of a grant program to States for the purpose of 
augmenting staffing levels. This provision, which is based on a 
initiative announced by President Clinton in mid-September, will 
support projects aimed at improving the recruitment and retention of 
direct nursing staff. The bill also requires nursing homes to post, on 
a daily basis, the number of staff and residents at the facility as 
well as submit staffing information to the Secretary.
  As a member of the Special Senate Committee on Aging, I am pleased to 
be an original cosponsor of the Nursing Home Staff Improvement Act, a 
balanced piece of legislation that I believe will go a long way in 
stabilizing nursing home staffing levels nationwide. I look forward to 
working with Senator Grassley and my other colleagues to enact this 
important legislation.
                                 ______