Safe Staffing Saves Lives Act

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:

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.

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.

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.

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.

A skilled nursing facility may not receive more than 2 consecutive waivers under this clause.

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.

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:

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.

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:

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).

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.

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.

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:

With respect

(II) ; and

(III) by adding at the end the following new clause:

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).

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)..

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:

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.

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.

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).

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:

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.

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.

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.

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.

A nursing facility may not receive more than 2 consecutive waivers under this clause.

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.

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.

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:

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.

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:

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).

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.

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.

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).

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)..

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:

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.

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.

(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).

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).

Section 1128I of the Social Security Act (42 U.S.C. 1320a–7j) is amended by adding at the end the following new subsection:

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.