H.R. 8100

[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>