,,ii #aaith ,,congress #b;d ,session ,s4 #chhf ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,february #ab1 #bjbf,mr4 ,wyden 7for himself1 ,mr4 ,kim1 ,mr4 ,booker1 ,ms4 ,warren1 ,mr4 ,lujn1 ,mr4 ,murphy1 and ,mr4 ,blumenthal7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to establish total nurse staffing hours per resident day1 to require #bd-;hour use of registered professional nurses in nursing homes1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,nurses ,belong in ,nursing ,homes ,act4 #b4 ,nurse staffing requirements 7a7 ,establishing total nurse staffing hours per resident day2 requiring #bd-;,hour use of registered professional nurses in nursing homes2 removal of waiver authority 7#a7 ,medicare ,section #ahai7;b77#d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#c7;b77#d77 is amended by striking subparagraph 7,c7 and inserting the following3 7,c7 ,required nursing care 7i7 ,in general ,a skilled nursing facility must provide-- 7,i7 #bd-;hour licensed nursing services which are sufficient to meet the nursing needs of its residents2 7,,ii7 not later than the date described in clause 7iii71 a minimum staffing requirement of at least #c4dh hours per resident day 7or the number of hours per resident day recommended in the report most recently submitted by the ,secretary under section #aabh,l7b77#b71 provided that such number is at least #c4dh hours per resident day7 of nursing care provided by a combination of a registered professional nurse1 licensed practical nurse 7or licensed vocational nurse71 or certified nursing assistant that-- 7aa7 provides direct care services to residents in a skilled nursing facility2 and 7bb7 reflects an appropriate combination of competencies and skills that is sufficient to ensure the safety of each resident in the facility2 and 7,,iii7 the services of a registered professional nurse1 such that such services are furnished-- 7aa7 before the date described in clause 7iii71 at least #h consecutive hours a day1 #g days a week2 and 7bb7 on or after such date1 #bd hours a day1 #g days a week4 7ii7 ,definition of hours per resident day ,in this subparagraph1 the term hours per resident day means the total number of hours worked by each type of staff described in clause 7i77,,ii7 divided by the total number of residents1 as calculated by the ,administrator of the ,centers for ,medicare ,medicaid ,services4 7iii7 ,date described ,for purposes of subclauses 7,,ii7 and 7,,iii7 of clause 7i71 the date described in this clause is the date that is #ahj days after the date of enactment of the ,nurses ,belong in ,nursing ,homes ,act4 4 7#b7 ,medicaid ,section #aiai7;b77#d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr7b77#d77 is amended by striking subparagraph 7,c7 and inserting the following3 7,c7 ,required nursing care 7i7 ,in general ,a nursing facility must provide-- 7,i7 #bd-;hour licensed nursing services which are sufficient to meet the nursing needs of its residents2 7,,ii7 not later than the date described in section #ahai7;b77#d77;,c77iii71 a minimum staffing requirement of at least #c4dh hours per resident day 7or the number of hours per resident day recommended in the report most recently submitted by the ,secretary under section #aabh,l7b77#b71 provided that such number is at least #c4dh hours per resident day7 of nursing care provided by a combination of a registered professional nurse1 licensed practical nurse 7or licensed vocational nurse71 or certified nursing assistant that-- 7aa7 provides direct care services to residents in a nursing facility2 and 7bb7 reflects an appropriate combination of competencies and skills that is sufficient to ensure the safety of each resident in the facility2 and 7,,iii7 the services of a registered professional nurse1 such that such services are furnished-- 7aa7 before the date described in section #ahai7;b77#d77;,c77iii71 at least #h consecutive hours a day1 #g days a week2 and 7bb7 on or after such date1 #bd hours a day1 #g days a week4 7ii7 ,definition of hours per resident day ,in this subparagraph1 the term hours per resident day has the meaning given such term in section #ahai7;b77#d77;,c77ii74 4 7b7 ,study ,title ,,xi of the ,social ,security ,act 7#db ,u4,s4,c4 #acja et seq47 is amended by inserting after section #aabh,k the following new section3 #aabh,l4 ,study and reports recommending minimum staffing requirements for skilled nursing facilities and nursing facilities2 promulgation of regulations 7a7 ,study 7#a7 ,in general ,not later than #b years after the date of enactment of this section1 and not less frequently than once every #d years thereafter1 the ,secretary shall direct the ,assistant ,secretary for ,planning and ,evaluation1 the ,comptroller ,general1 or the ,medicare ,payment ,advisory ,commission1 in consultation with the ,medicaid and ,,chip ,payment and ,access ,commission 7in this section referred to as the designated entity71 to complete a study analyzing nurse staffing requirements at skilled nursing facilities 7as defined in section #ahai7;a77 and nursing facilities 7as defined in section #aiai7;a77 to provide care to individuals seeking their services4 7#b7 ,contents ,with respect to each study required under paragraph 7#a71 the designated entity shall-- 7,a7 consult with-- 7i7 residents1 family members of residents1 or authorized representatives of residents2 7ii7 registered professional nurses1 licensed practical nurses 7or licensed vocational nurses71 certified nursing assistants1 and other categories of direct care professionals 7as determined by the ,secretary7 who work at such skilled nursing facilities or nursing facilities2 7iii7 collective bargaining units or unions that represent direct care workers or direct care professionals who work at such skilled nursing facilities and nursing facilities2 7iv7 operators of nursing facilities and skilled nursing facilities2 7v7 researchers with expertise in the nursing home and long-term care workforce1 including the disclosure of funding sources for previously conducted research and conflicts of interest2 and 7vi7 long-term care ombudsmen2 and 7,b7 address the following3 7i7 ,whether the minimum staffing requirements established in sections #ahai7;b77#d77;,c77i77,,ii7 and #aiai7;b77#d77;,c77i77,,ii7 should be maintained or increased 7but in no event decreased below a minimum staffing requirement of at least #c4dh hours per resident day71 based on the severity of the health conditions1 complexity of health care needs1 or other measures of patient acuity of residents at such skilled nursing facilities and nursing facilities1 and1 if so1 how such minimum staffing requirements shall be increased4 7ii7 ,whether other minimum hours per resident day minimum staffing requirements should be established for other categories of direct care professionals or direct care workers in addition to the requirements established in sections #ahai7;b77#d77;,c77i77,,ii7 and #aiai7;b77#d77;,c77i77,,ii74 7iii7 ,a review of staffing1 safety1 and quality data1 as well as staffing requirement exception data1 to assess the adequacy of existing staffing practices in such nursing facilities and skilled nursing facilities4 7b7 ,reports 7#a7 ,to the ,secretary ,the designated entity shall submit to the ,secretary a report on the results of the study conducted under subsection 7a71 together with recommendations for such legislation and administrative action as the designated entity determines appropriate4 7#b7 ,to ,congress ,not later than #ahj days after receiving each report under paragraph 7#a71 the ,secretary shall submit to ,congress a report on-- 7,a7 the findings and recommendations included in such report2 and 7,b7 any plan to implement such recommendations1 including a justification for any recommendations the ,secretary determines should not be implemented4 7c7 ,regulations 7#a7 ,in general ,not later than #a year after the ,secretary submits an initial report under subsection 7b77#b71 the ,secretary shall-- 7,a7 specify through regulations1 consistent with such report1 a minimum staffing requirement for nursing staff for skilled nursing facilities 7as defined in section #ahai7;a77 and nursing facilities 7as defined in section #aiai7;a772 and 7,b7 require such skilled nursing facilities and such nursing facilities to comply with such staffing requirements1 including by providing the minimum staffing sufficient to meet the needs of each resident in any such facility4 7#b7 ,update ,not later than #a year after the ,secretary submits each subsequent report under subsection 7b77#b71 the ,secretary shall1 consistent with each such report1 update the regulations described in paragraph 7#a77;,a7 as necessary4 7d7 ,funding ,the ,secretary shall provide for the transfer1 from the ,federal ,hospital ,insurance ,trust ,fund under section #ahag to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account1 of #ej1jjj1jjj for fiscal year #bjbg for purposes of carrying out this section4 ,amounts transferred pursuant to the previous sentence shall remain available until expended4 4 7c7 ,rule of construction ,the moratorium imposed under section #gaaaa of the ,act titled ,an ,act to provide for reconciliation pursuant to title ,,ii of ,h4 ,con4 ,res4 #ad 7,public ,law #aai-ba7 7relating to implementation of certain staffing standards for long-term care facilities under the ,medicare and ,medicaid programs7 shall not be construed to apply to the amendments made by this section4 #c4 ,permanent funding for the ,survey and ,certification ,program for nursing homes and other health care entities ,part ,a of ,title ,,xi of the ,social ,security ,act 7#db ,u4,s4,c4 #acja et seq47 is amended by inserting after section #aaej;,c the following new section3 #aaej;,d4 ,funding for the ,survey and ,certification ,program ,there is appropriated to the ,secretary1 out of the ,federal ,hospital ,insurance ,trust ,fund under section #ahag and the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda 7in such proportions as the ,secretary determines to be appropriate71 #hjj1jjj1jjj for fiscal year #bjbg and each subsequent fiscal year for the purpose of conducting the ,secretary's ,survey and ,certification ,program1 including under section #ahfd4 ,amounts appropriated under the preceding sentence shall remain available until expended4 4 #d4 ,investing in the nursing home workforce 7a7 ,medicare ,section #ahai7;h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#c7;h77 is amended-- 7#a7 in paragraph 7#b77;,b77ii77,,iv77ff71 by inserting 1 provided that not less than half of such amounts are provided to the ,state in which the facility is located for the purposes described in paragraph 7#g71 after collected may2 and 7#b7 by adding at the end the following new paragraph3 7#g7 ,use of civil money penalty amounts to support the skilled nursing facility workforce 7,a7 ,in general ,subject to subparagraph 7,b71 a ,state shall use the amounts provided to such ,state pursuant to paragraph 7#b77;,b77ii77,,iv77ff7 for the fiscal year in which such amounts are provided for the following purposes3 7i7 ,providing grants to entities such as educational institutions1 advocacy organizations for skilled nursing facility residents1 senior citizens1 or individuals with disabilities1 and unions that represent the skilled nursing facility workforce to support projects that use community-driven approaches to recruit1 educate1 and train individuals to expand the skilled nursing facility workforce4 7ii7 ,the funding of projects that develop new career pathway programs for the skilled nursing facility workforce4 7iii7 ,the repayment of student loans for qualified skilled nursing facility providers 7as defined in subparagraph 7,c77 or the payment of tuition for such providers who commit to serving in a skilled nursing facility or a nursing facility 7as defined in section #aiai7;a77 for not less than #c years within a #aj-year period4 7,b7 ,prohibitions on use of funds 7i7 ,prohibition on providing funds to entities related to facilities ,a ,state may not provide any amounts provided to such ,state pursuant to paragraph 7#b77;,b77ii77,,iv77ff7 to an entity that has a related party relationship with a nursing facility or skilled nursing facility in such ,state4 7ii7 ,prohibition on using funds for reimbursement of costs incurred in completing nurse aide training and competency evaluation programs and nurse aide competency evaluation programs ,a ,state may not use any amounts provided to such ,state pursuant to paragraph 7#b77;,b77ii77,,iv77ff7 to-- 7,i7 reimburse costs incurred in completing a nurse aide training and competency evaluation program or a nurse aide competency evaluation program under subsection 7f77#b77;,a72 or 7,,ii7 supplant the payment of such costs under such subsection4 7,c7 ,definitions ,in this paragraph3 7i7 ,qualified skilled nursing facility provider ,the term qualified skilled nursing facility provider means-- 7,i7 a geriatrician or other physician1 nurse practitioner1 physician assistant1 or other practitioner who provides services in a skilled nursing facility or nursing facility2 or 7,,ii7 a registered professional nurse1 a licensed practical nurse 7or a licensed vocational nurse71 or a certified nursing assistant who provides direct care services to residents in a skilled nursing facility or nursing facility1 as determined by the ,secretary4 7ii7 ,related party ,the term related party means an entity that1 to a significant extent is associated or affiliated with1 or has control of1 or is controlled by1 a nursing facility or skilled nursing facility4 7,d7 ,annual reporting 7i7 ,report from ,states ,not later than #a year after the date of enactment of this paragraph1 and annually thereafter1 each ,state that receives amounts pursuant to paragraph 7#b77;,b77ii77,,iv77ff7 shall submit to the ,secretary a report describing-- 7,i7 how amounts received in the previous fiscal year were allocated2 7,,ii7 the mechanisms to ensure such amounts benefit the development of the skilled nursing facility workforce2 7,,iii7 how such amounts will impact measurable outcomes for residents of skilled nursing facilities and nursing facilities1 such as staff vacancy rates1 turnover rates1 median hourly wages1 staffing hours per resident1 and resident quality outcomes2 and 7,,iv7 how such ,state is ensuring compliance with subparagraph 7,b74 7ii7 ,report to ,congress ,not later than #ahj days after the ,secretary receives the annual reports from ,states under clause 7i71 the ,secretary shall submit to ,congress a report describing the information contained in such reports4 4 7b7 ,medicaid ,section #aiai7;h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr7h77 is amended-- 7#a7 in paragraph 7#b77;,a77ii7-- 7,a7 in the second sentence1 by striking ,funds collected and inserting ,subject to the last sentence of this clause1 funds collected2 and 7,b7 by inserting the following sentence at the end3 ,not less than half of the funds collected pursuant to this clause shall be used for the purposes described in paragraph 7#aj742 7#b7 in paragraph 7#c77;,c77ii77,,iv77ff71 by inserting 1 provided that not less than half of such amounts are provided to the ,state in which the facility is located for the purposes described in paragraph 7#aj712 and 7#c7 by adding at the end the following new paragraph3 7#aj7 ,use of civil money penalty amounts to support the nursing facility workforce 7,a7 ,in general ,subject to subparagraph 7,b71 a ,state shall use not less than half of the funds collected under paragraph 7#b77;,a77ii7 and the amounts provided to such ,state pursuant to paragraph 7#c77;,c77ii77,,iv77ff7 7collectively referred to in this paragraph as civil money penalty amounts7 for the fiscal year in which such amounts are collected or provided for the following activities3 7i7 ,providing grants to entities such as educational institutions1 advocacy organizations for nursing facility residents1 senior citizens1 or individuals with disabilities1 and unions that represent the nursing facility workforce to support projects that use community-driven approaches to recruit1 educate1 and train individuals to expand the nursing facility workforce4 7ii7 ,the funding of projects that develop new career pathway programs for the nursing facility workforce4 7iii7 ,the repayment of student loans for qualified nursing facility providers 7as defined in subparagraph 7,c77 or the payment of tuition for such providers who commit to serving in a skilled nursing facility 7as defined in section #ahai7;a77 or a nursing facility for not less than #c years within a #aj-year period4 7,b7 ,prohibition on use of funds 7i7 ,prohibition on providing funds to entities related to facilities ,a ,state may not provide any civil money penalty amounts to an entity that has a related party relationship with a nursing facility or skilled nursing facility in such ,state4 7ii7 ,prohibition on using funds for reimbursement of costs incurred in completing nurse aide training and competency programs and nurse aide competency evaluation programs ,a ,state may not use any civil money penalty amounts to-- 7,i7 reimburse costs incurred in completing a nurse aid training and competency evaluation program or a nurse aide competency evaluation program under subsection 7f77#b77;,a72 or 7,,ii7 supplant the payment of such costs under such subsection4 7,c7 ,definitions ,in this paragraph3 7i7 ,qualified nursing facility provider ,the term qualified nursing facility provider means-- 7,i7 a geriatrician or other physician1 nurse practitioner1 physician assistant1 or other practitioner who provides services in a skilled nursing facility or nursing facility2 or 7,,ii7 a registered professional nurse1 licensed practical nurse 7or a licensed vocational nurse71 or certified nursing assistant who provides direct care services to residents in a skilled nursing facility or nursing facility1 as determined by the ,secretary4 7ii7 ,related party ,the term related party means an entity that1 to a significant extent is associated or affiliated with1 or has control of1 or is controlled by1 a nursing facility or skilled nursing facility4 7,d7 ,annual reporting 7i7 ,report from ,states ,not later than #a year after the date of enactment of this paragraph1 and annually thereafter1 each ,state that receives any civil money penalty amounts shall submit to the ,secretary a report describing-- 7,i7 how amounts received in the previous fiscal year were allocated2 7,,ii7 the mechanisms to ensure such amounts benefit the development of the nursing facility workforce2 7,,iii7 how such amounts will impact measurable outcomes for residents of skilled nursing facilities and nursing facilities1 such as staff vacancy rates1 turnover rates1 median hourly wages1 staffing hours per resident1 and resident quality outcomes2 and 7,,iv7 how such ,state is ensuring compliance with subparagraph 7,b74 7ii7 ,report to ,congress ,not later than #ahj days after the ,secretary receives the annual reports from ,states under clause 7i71 the ,secretary shall submit to ,congress a report describing the information contained in such report4 4 #e4 ,codification of regulations regarding requirements for long-term services and supports and payment transparency reporting ,sections #dch4gb and #ddb4dc of title #db1 ,code of ,federal ,regulations 7as in effect on ,may #aj1 #bjbd71 shall have the force and effect of law4