[Congressional Record Volume 154, Number 25 (Thursday, February 14, 2008)]
[Senate]
[Pages S1058-S1059]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. GRASSLEY (for himself and Mr. Kohl):
  S. 2641. A bill to amend title XVIII and XIX of the Social Security 
Act to improve the transparency of information on skilled nursing 
facilities and nursing facilities and to clarify and improve the 
targeting of the enforcement of requirements with respect to such 
facilities; to the Committee on Finance.
  Mr. GRASSLEY. Mr. President, I come to the floor for the purpose of 
introducing a bill. The bill's title is the Nursing Home Transparency 
and Improvement Act of 2008.
  I introduce this bill along with Senator Kohl of Wisconsin. It is a 
bipartisan bill. Senator Kohl, because he is in the majority, has the 
distinguished pleasure of serving as chairman of a special committee on 
aging which is also a very important responsibility, particularly since 
our Government spends about more than $50 billion a year on nursing 
home care for elderly, among other things that are the responsibility 
tie of that committee.
  The bill that we are introducing is an important piece of legislation 
that aims to bring some overdue transparency to consumers regarding 
nursing home quality. It also provides long-needed improvements to our 
enforcement system.
  This legislation further strengthens nursing home staff training 
requirements. In America today, there are over 1.7 million elderly and 
disabled individuals in roughly 17,000 nursing homes.
  As the baby boom generation ages, that number probably will rise, 
unless we do something about the problems of osteoporosis and 
Alzheimer's and diabetes. Hopefully, we can do those things so our 
nursing homes do not fill up more. But those are some of the health 
problems that are facing 77 million baby boomers. Some of them 
undoubtedly will end up in nursing homes.
  So we have to have not only a tremendous interest in ensuring nursing 
home quality based upon the number of people who are already there, but 
we are going to have more in the future.
  While many people are using alternatives such as home care or other 
methods of community-based care, nursing homes are going to remain a 
critical option for our elderly and our disabled. I always think in 
terms of nursing homes being at the end of a continuum of care for 
people who need some help.
  People want to stay in their own home. When there is a question, can 
they do that without endangering them, bring some help to the home, 
relatives or home health care types.
  If that is not the right environment, then assisted living. And then 
other things that might eventually bring a person to a nursing home. 
But a nursing home is a last resort. I say that because during my 
tenure as chairman of the Aging Committee from 1997 to the year 2001, 
versus the period of time I was chairman of the Senate Finance 
Committee, dealing with a lot of aging issues, interacting with a lot 
of older people, I have never once had anybody say to me that: I am 
just dying to get into a nursing home.
  So I think it is important we do whatever we can to keep people out 
of nursing homes. But there are some people, a lot of people, and a 
growing number of people who are going to need that type of care.
  So we have to be concerned about the quality of care in nursing 
homes. We surely owe it to them to make sure they receive the safe and 
quality care they deserve. Unfortunately in many areas, the nursing 
homes, we have a few bad apples always spoiling the barrel. Too many 
Americans receive poor care, often in a subset of a nursing home.
  Unfortunately, this subset of chronic offenders stays in business, in 
many ways keeping their poor track records hidden from the public at 
large and often facing little or no enforcement from the Federal 
Government.
  As ranking member of the Senate Finance Committee, I have a 
longstanding commitment to ensuring that nursing home residents receive 
the safe and quality care we expect for our own loved ones. But this 
effort requires transparency, transparency in the nursing home industry 
so consumers are armed with information, consumers having information 
they need to make the best decisions possible for loved ones. This same 
transparency also provides additional market incentives for bad homes 
to improve.
  This effort also requires a strong mandatory enforcement and 
monitoring system to ensure safe and quality care at facilities that 
would not take the steps needed to do so voluntarily.
  The Grassley-Kohl legislation seeks to strengthen both areas, 
transparency and enforcement. It is a bill that is good for consumers, 
good for nursing home residents, and good even for the nursing home 
community.
  Let's look at transparency. In the market for nursing home care, 
similar to all markets, consumers must have adequate data to make 
informed choices. For years people looking at a nursing home for 
themselves or loved ones had no way of knowing whether that home was--
this is kind of a legal term in the regulations--a ``special focus 
facility,'' a designation meaning they had been singled out as a 
consistently poor performer.
  Why should consumers not have access to this information? The 
Government has it and so should consumers. To that end, this bill 
requires that the ``special focus facilities'' designation be placed on 
the CMS website. Nursing Home Compare is the name of that website.

  By giving consumers this information, we will both give consumers 
information necessary to make informed choices and poorly performing 
homes an extra incentive to shape up or consumers then can go 
elsewhere.
  This bill also requires more transparency about ownership 
information. What is so secretive about who owns a nursing home? Also, 
it provides transparency in inspection reports and more accountability 
for large nursing home chains and the development of a standardized 
resident complaint form so there is a clear and easy way to report 
problems and have them resolved.
  The bill would also bring more transparency on what portion of a 
nursing home's spending is used for direct care for residents and also 
bring more uniformity to the reporting of nursing staffing levels so 
people can make an apples-to-apples comparison between nursing homes.
  But even with improved transparency, there are some nursing homes 
that will not improve on their own. In the nursing home industry, most 
homes provide quality care on a consistent basis. But as in many 
sectors, this industry is given a bad name by a few bad apples that 
spoil the barrel.
  So we need to give inspectors better enforcement tools. The current 
system provides incentives to correct problems only temporarily and 
allows homes to avoid regulatory sanctions while continuing to deliver 
substandard care to residents. That system must be fixed.
  In ongoing correspondence that I have had with Terry Weems, the 
Acting Administrator of CMS, that agency has requested the statutory 
authority to collect civil monetary penalties sooner and hold them in 
escrow pending appeal. To that end, this bill requires penalties be 
collected within 90 days following a hearing; after that, they be held 
in escrow pending appeal.
  Penalties should also be meaningful. Too often they are assessed at 
the lowest possible amount, if at all. Penalties should be more than 
merely the cost of doing business, they should be collected in a 
reasonable timeframe and should not be rescinded easily.
  These changes would help prod the industry's bad actors to get their 
act together or get out of business. In addition to increased 
transparency and improved enforcement, this bill provides commonsense 
solutions to a number of other problems as well.
  This legislation requires the Secretary of Health and Human Services 
to establish a national independent

[[Page S1059]]

monitoring program to tackle problems specific to interstate and large 
intrastate nursing home chains. This legislation directs the Government 
Accountability Office to, one, conduct studies on the role, if any, of 
financial problems in the poor performance of special focus facilities; 
identify best practices at the State level in temporary management 
programs; and, three, determine what are the barriers preventing the 
purchase of nursing homes with a record of poor quality.
  Finally, in the case of nursing homes being closed due to prior 
safety or quality of care, the bill requires that residents and their 
representatives be given a sufficient notice so they can adequately 
plan a transfer to a better performing nursing home. I happen to be 
very sensitive to the fact that nursing home residents are often old 
and fragile. Moving them into new facilities is often very traumatic. 
So we have to make sure these residents are transferred appropriately 
and with the time and care deserved.
  This bill would also strengthen training requirements for nursing 
staff, by including dementia and abuse prevention training as part of 
the preemployment training.
  The Grassley-Kohl bill also requires a study on the appropriateness 
of increasing training requirements for nurse aids and supervisory 
staff.
  I am proud to introduce this bill today, along with the distinguished 
Senator from Wisconsin, Mr. Kohl, the chairman of the Aging Committee. 
He and I have a long history of working on issues together, 
particularly for the elderly. We will continue to do everything we can 
to make sure America's nursing home residents receive the safe and 
quality care they deserve. Increasing transparency, improved 
enforcement tools, and strengthening training requirements will go a 
long way toward achieving this goal.
  Mr. KOHL. Mr. President, I rise today to introduce the Nursing Home 
Transparency and Improvement Act of 2008 with my distinguished 
colleague, Senator Grassley. Senator Grassley conducted a great deal of 
valuable oversight for nursing homes during his tenure as Aging 
Committee chairman from 1997 through 2000, and he continues to make 
major contributions in this area today. Working toward higher standards 
of nursing home quality is a tradition of which I am proud to be a 
part.
  It is staggering to think that the most recent major law dictating 
Federal standards for quality, for data reporting, and for enforcement 
was passed in 1987. Twenty-one years later, we know that it has spurred 
important improvements in the quality of care provided in nursing 
homes. Yet we are far from finished, and there are additional 
improvements that need to be made.
  The first is in the area of transparency. If consumers can easily 
tell which homes have a solid enforcement track record, which are well-
staffed, which are owned by a chain with a good reputation for 
providing excellent services--and which homes are not--then this sort 
of disclosure can serve as a powerful motivation for homes to provide 
the best possible care, to hire and keep the most dedicated staff, and 
to always prioritize the interests of residents. The court of public 
opinion and the strength of market forces are powerful and inexpensive 
tools we should be putting to good use.
  Our legislation will make sure all this information is available to 
consumers in a timely and easy-to-use fashion. We want Americans to be 
able to use the Federal Government's Web site, Nursing Home Compare, 
with ease. We want Americans to have access to the type of information 
that matters, such as the number of hours of care their loved one will 
receive from staff every day. We want Americans to be able to use this 
Web site to lodge complaints of mistreatment or neglect. These are 
simple, effective ideas, and our bill will make them a reality.
  The second area in need of improvement is our Government's system of 
nursing home quality enforcement. Under the current system, nursing 
homes that are not providing good care, or--even worse--are putting 
their residents in harms way, can escape penalty from the Government by 
abusing a lengthy appeal process, while they slip in and out of 
compliance with Federal regulations. This is unacceptable. We need the 
threat of sanctions to mean something--and under my bill with Senator 
Grassley, they will. Our legislation will require that all civil 
monetary penalties be collected and placed in an escrow account as soon 
as they are levied, pending the final resolution of any appeal. 
Financial penalties will be increased for serious quality deficiencies 
that cause actual harm to nursing home residents or put them in 
``immediate jeopardy.''
  In addition, our policy enables regulators to respond effectively 
when serious quality problems are evident in order to protect the 
safety of residents. The bill requires that States and facilities 
provide a secure and orderly process when relocating residents due to a 
nursing home closure. It also proposes national demonstrations to 
promote innovations in information technology and ``culture change'' in 
order to improve resident care.
  The Federal Government now spends $75 billion annually on nursing 
homes through Medicare and Medicaid, and spending is projected to rise 
as costs associated with the boomer generation increase. Congress has a 
responsibility to demand high-quality services for residents and 
accountability from the nursing home industry in return for this huge 
investment of public resources. I urge my colleagues to join Senator 
Grassley and myself in sponsoring this commonsense piece of 
legislation.
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