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Senate
File
527
-
Introduced
SENATE
FILE
527
BY
CELSI
A
BILL
FOR
An
Act
relating
to
nursing
facility
staffing
requirements.
1
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
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Section
1.
NEW
SECTION
.
135.35D
Nursing
facilities
——
1
staffing
requirements.
2
1.
For
purposes
of
this
section:
3
a.
“Certified
nurse
aide
training
program”
means
the
same
as
4
defined
in
section
135C.33.
5
b.
“Nurse
aide”
means
a
person
who
successfully
completed
a
6
certified
nurse
aide
training
program.
7
c.
“Physician”
means
a
person
licensed
under
chapter
148.
8
d.
“Registered
nurse”
means
a
person
licensed
under
chapter
9
152
or
152E.
10
e.
“Resident
assessment”
means
a
resident
assessment
11
conducted
under
42
C.F.R.
§483.20.
12
f.
“Resident
care
plan”
means
the
contract
between
a
nursing
13
facility
and
a
resident
that
outlines
how
the
nursing
facility
14
will
provide
care
for
the
resident.
15
2.
A
nursing
facility
must
have
sufficient
staff
with
the
16
appropriate
competencies
and
skill
sets
to
provide
nursing
17
care
and
related
services
to
ensure
resident
safety
and
attain
18
the
highest
practicable
physical,
mental,
and
psychosocial
19
well-being
of
each
resident,
as
determined
by
resident
20
assessments
and
individual
resident
care
plans
and
considering
21
the
number,
acuity,
and
diagnoses
of
the
nursing
facility’s
22
residents.
23
3.
a.
A
nursing
facility
shall
provide
nursing
care
on
a
24
twenty-four-hour
basis
in
accordance
with
each
resident
care
25
plan
by
employing
sufficient
numbers
of
each
of
the
following
26
types
of
personnel:
27
(1)
Licensed
nurses.
28
(2)
Other
nursing
personnel,
including
but
not
limited
to
29
nurse
aides.
30
b.
A
nursing
facility
shall
designate
a
licensed
nurse
to
31
serve
as
a
charge
nurse
on
each
tour
of
duty.
The
charge
nurse
32
shall
assume
leadership
responsibility
by
overseeing
nursing
33
care
and
addressing
immediate
concerns
within
the
nursing
34
facility.
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c.
A
nursing
facility
shall
ensure
that
licensed
nurses
have
1
the
specific
competencies
and
skill
sets
necessary
to
care
for
2
residents’
needs,
as
identified
through
resident
assessments
3
and
described
in
each
resident
care
plan.
4
d.
For
purposes
of
this
subsection,
“nursing
care”
includes
5
but
is
not
limited
to
assessing,
evaluating,
planning,
and
6
implementing
resident
care
plans
and
responding
to
residents’
7
needs.
8
4.
a.
A
nursing
facility
must
provide
a
minimum
of
three
9
and
forty-eight
hundredths
hours
per
resident
per
day
for
total
10
nurse
staffing,
including
but
not
limited
to
the
following:
11
(1)
A
minimum
of
fifty-five
hundredths
hours
per
resident
12
per
day
for
registered
nurses.
13
(2)
A
minimum
of
two
and
forty-five
hundredths
hours
per
14
resident
per
day
for
nurse
aides.
15
b.
Paragraph
“a”
shall
not
be
construed
as
setting
minimum
16
staffing
levels.
17
5.
a.
A
nursing
facility
shall
have
a
registered
nurse
on
18
site
twenty-four
hours
per
day
that
is
available
to
provide
19
direct
resident
care.
20
b.
For
any
periods
when
the
requirement
in
paragraph
“a”
21
is
exempted
under
subsection
11,
a
nursing
facility
shall
22
have
a
registered
nurse,
a
physician
assistant
licensed
under
23
chapter
148C,
or
a
physician
available
to
respond
immediately
24
to
telephone
calls
from
the
nursing
facility.
25
c.
A
nursing
facility
shall
designate
a
registered
nurse
26
to
serve
as
the
director
of
nursing
on
a
full-time
basis.
The
27
director
of
nursing
may
serve
as
a
charge
nurse
only
when
the
28
nursing
facility
has
an
average
daily
occupancy
of
sixty
or
29
fewer
residents.
30
6.
A
nursing
facility
shall
employ
or
contract
with
at
31
least
one
physician
that
will
evaluate
each
resident
for
wounds
32
and
infections
on
a
weekly
basis.
The
physician
shall
treat
33
or
recommend
a
treatment
for
each
of
a
resident’s
identified
34
wounds
and
infections.
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7.
A
nursing
facility
shall
ensure
that
nurse
aides
are
able
1
to
demonstrate
competency
in
skills
and
techniques
necessary
2
to
care
for
residents’
needs
as
identified
through
resident
3
assessments
and
described
in
each
resident
care
plan.
4
8.
a.
Before
employing
an
individual
as
a
nurse
aide,
5
a
nursing
facility
shall
verify
that
the
individual
has
met
6
competency
evaluation
requirements
unless
any
of
the
following
7
apply:
8
(1)
The
individual
is
a
full-time
employee
in
a
certified
9
nurse
aide
training
program.
10
(2)
The
individual
can
prove
that
the
individual
has
11
recently
completed
a
certified
nurse
aide
training
program
12
and
has
not
yet
been
included
in
the
department’s
nurse
aide
13
registry.
A
nursing
facility
shall
ensure
that
the
individual
14
actually
becomes
included
in
the
nurse
aide
registry.
15
b.
Before
employing
an
individual
as
a
nurse
aide,
a
nursing
16
facility
shall
obtain
information
from
every
state
registry
17
established
under
section
1819(e)(2)(A)
or
1919(e)(2)(A)
of
18
the
federal
Social
Security
Act
that
the
nursing
facility
has
19
reason
to
believe
will
include
information
on
the
individual.
20
c.
If
an
individual
has
not
provided
nursing
care
or
21
related
services
for
monetary
compensation
for
the
most
recent
22
twenty-four
consecutive
months,
the
individual
shall
complete
23
another
certified
nurse
aide
training
program.
24
d.
A
nursing
facility
shall
conduct
a
performance
review
25
of
every
nurse
aide
at
least
once
every
twelve
months,
and
26
shall
provide
regular
in-service
education
based
on
the
outcome
27
of
these
reviews.
In-service
training
shall
comply
with
the
28
requirements
of
42
C.F.R.
§483.95(g).
29
9.
a.
The
department
may
waive
the
requirements
of
30
subsection
3,
paragraph
“a”
,
or
subsection
4,
paragraph
“a”
,
31
subparagraph
(1),
or
subsection
5,
paragraph
“a”
,
for
a
nursing
32
facility
that
is
unable
to
meet
the
requirements
if
all
of
the
33
following
apply:
34
(1)
The
nursing
facility
demonstrates
that
the
nursing
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facility
has
been
unable,
despite
diligent
efforts,
to
recruit
1
appropriate
personnel.
Diligent
efforts
shall
include
but
not
2
be
limited
to
offering
wages
at
the
community
prevailing
rate
3
for
nursing
facilities.
4
(2)
The
department
determines
that
a
waiver
of
the
5
requirement
will
not
endanger
the
health
or
safety
of
the
6
nursing
facility’s
residents.
7
(3)
The
department
determines
that,
for
any
periods
in
which
8
licensed
nursing
care
is
not
available,
a
registered
nurse
or
9
a
physician
is
obligated
to
respond
immediately
to
telephone
10
calls
from
the
nursing
facility.
11
b.
A
waiver
granted
under
paragraph
“a”
is
subject
to
annual
12
department
review.
13
c.
In
granting
or
renewing
a
waiver,
the
department
may
14
require
a
nursing
facility
to
use
other
qualified,
licensed
15
personnel.
16
d.
The
department
shall
provide
notice
of
a
waiver
granted
17
under
paragraph
“a”
to
the
office
of
long-term
care
ombudsman
18
established
under
section
231.42,
and
a
representative
of
the
19
protection
and
advocacy
agency
designated
by
the
state
under
20
section
135C.2.
21
e.
A
nursing
facility
that
is
granted
a
waiver
under
22
paragraph
“a”
shall
notify
its
residents
and
the
residents’
23
representatives
of
the
waiver.
24
10.
a.
The
department
may
waive
the
requirement
that
a
25
nursing
facility
provide
the
services
of
a
registered
nurse
for
26
more
than
forty
hours
per
week,
including
a
director
of
nursing
27
specified
in
subsection
5,
paragraph
“c”
,
if
the
department
28
finds
all
of
the
following:
29
(1)
The
nursing
facility
is
located
in
a
rural
area
and
30
the
supply
of
nursing
facility
services
in
the
area
is
not
31
sufficient
to
meet
the
needs
of
individuals
residing
in
the
32
area.
33
(2)
The
nursing
facility
has
one
full-time
registered
nurse
34
who
is
regularly
on
duty
at
the
facility
forty
hours
per
week.
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(3)
Any
of
the
following
apply
to
the
nursing
facility:
1
(a)
The
nursing
facility
only
has
patients
whose
physicians
2
have
indicated
that
they
do
not
require
the
services
of
a
3
registered
nurse
or
a
physician
for
a
forty-eight-hour
period.
4
(b)
The
nursing
facility
has
made
arrangements
for
a
5
registered
nurse
or
a
physician
to
spend
time
at
the
nursing
6
facility,
as
determined
necessary
by
the
physician,
to
provide
7
necessary
skilled
nursing
care
on
days
when
the
regular
8
full-time
registered
nurse
is
not
on
duty.
9
b.
The
department
shall
provide
notice
of
a
waiver
granted
10
under
paragraph
“a”
to
the
office
of
long-term
care
ombudsman
11
established
under
section
231.42,
and
a
representative
of
the
12
protection
and
advocacy
agency
designated
by
the
state
under
13
section
135C.2.
14
c.
A
nursing
facility
that
is
granted
a
waiver
under
15
paragraph
“a”
shall
notify
its
residents
and
the
residents’
16
representatives
of
the
waiver.
17
d.
A
waiver
of
the
registered
nurse
requirement
under
18
paragraph
“a”
is
subject
to
annual
renewal
by
the
department.
19
11.
a.
The
department
may
waive
the
requirements
under
20
subsection
4,
paragraph
“a”
,
or
subsection
5,
paragraph
“a”
,
21
for
a
nursing
facility
if
a
hardship
exists
that
prohibits
the
22
nursing
facility
from
achieving
or
maintaining
compliance
and
23
the
nursing
facility
meets
the
following
criteria:
24
(1)
The
nursing
facility
is
located
in
an
area
where
the
25
supply
of
health
care
staff
is
not
sufficient
to
meet
area
26
needs
as
evidenced
by
a
provider-to-population
ratio
for
the
27
nursing
workforce
that
is
a
minimum
of
twenty
percent
below
28
the
national
average,
as
calculated
by
the
federal
centers
for
29
Medicare
and
Medicaid
services.
If
the
ratio
of
a
nursing
30
facility’s
registered
nurse
and
nurse
aide
population
compared
31
to
the
population
of
the
surrounding
geographic
area
is
a
32
minimum
of
twenty
percent
below
the
national
average,
the
33
department
may
waive
any
of
the
following:
34
(a)
The
total
nurse
staffing
requirements
under
subsection
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4,
paragraph
“a”
.
1
(b)
The
hours
per
resident
per
day
requirement
under
2
subsection
4,
paragraph
“a”
,
subparagraph
(1).
3
(c)
The
hours
per
resident
per
day
requirement
under
4
subsection
4,
paragraph
“a”
,
subparagraph
(2).
5
(d)
Up
to
eight
hours
per
day
from
the
on-site
registered
6
nurse
requirement
under
subsection
5,
paragraph
“a”
.
7
(2)
The
nursing
facility
demonstrates
that
it
has
been
8
unable,
despite
diligent
efforts,
to
recruit
and
retain
9
appropriate
personnel.
Evidence
of
diligent
efforts
include
10
but
are
not
limited
to
all
of
the
following:
11
(a)
Wages
offered
at
the
community
prevailing
rate
for
12
nursing
facilities.
13
(b)
Jobs
listed
in
commonly
used
recruitment
forums
found
14
online
and
other
forums
as
appropriate.
15
(c)
Documented
job
vacancies
including
the
number
and
16
duration
of
the
vacancies
and
documentation
of
offers
made
at
17
least
at
the
community
prevailing
rate
for
nursing
facilities.
18
(d)
Data
on
the
average
wages
in
the
metropolitan
19
statistical
area
in
which
the
facility
is
located,
and
20
vacancies
by
industry
as
reported
by
the
federal
bureau
of
21
labor
statistics
or
by
the
department
of
workforce
development.
22
(e)
Documentation
of
the
nursing
facility’s
financial
23
resources
that
shows
the
amount
the
nursing
facility
expends
on
24
nurse
staffing
relative
to
revenue.
25
b.
A
nursing
facility
granted
a
waiver
under
paragraph
“a”
26
shall
do
all
of
the
following:
27
(1)
Post
in
a
prominent
location
in
the
nursing
facility,
28
and
in
a
form
and
manner
accessible
and
understandable
to
29
residents
and
the
residents’
representatives,
a
notice
of
30
the
nursing
facility’s
exemption
status,
the
extent
to
which
31
the
nursing
facility
does
not
meet
the
minimum
staffing
32
requirements,
and
the
time
frame
during
which
the
exemption
33
applies.
34
(2)
Provide
to
each
resident
or
the
resident’s
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representative,
and
to
each
prospective
resident
or
the
1
prospective
resident’s
representative,
a
notice
of
the
nursing
2
facility’s
exemption
status,
including
the
extent
to
which
the
3
nursing
facility
does
not
meet
the
staffing
requirements,
the
4
time
frame
during
which
the
exemption
applies,
and
a
statement
5
reminding
residents
of
their
rights
to
contact
advocacy
and
6
oversight
entities
as
provided
in
the
notice
provided
to
them
7
under
42
C.F.R.
§483.10(g)(4).
8
(3)
Send
a
copy
of
the
notice
under
subparagraph
(2)
to
9
a
representative
of
the
office
of
long-term
care
ombudsman
10
established
under
section
231.42.
11
c.
A
nursing
facility
is
not
eligible
for
a
waiver
under
12
this
subsection
if
any
of
the
following
apply:
13
(1)
The
nursing
facility
is
a
special
focus
facility,
14
pursuant
to
the
special
focus
facility
program
established
15
under
sections
1819(f)(8)
and
1919(f)(10)
of
the
federal
Social
16
Security
Act.
17
(2)
The
nursing
facility
received
a
citation
for
having
18
widespread
insufficient
staffing
or
a
pattern
of
insufficient
19
staffing
that
resulted
in
actual
harm.
20
(3)
The
nursing
facility
received
a
citation
for
immediate
21
jeopardy
due
to
insufficient
staffing.
22
(4)
The
nursing
facility
failed
to
submit
payroll-based
23
journal
data
in
accordance
with
42
C.F.R.
§483.70(p).
24
d.
A
nursing
facility
shall
provide
documentation
when
25
requested
by
the
department
while
the
department
determines
26
the
nursing
facility’s
eligibility
for
a
waiver
under
this
27
subsection.
28
e.
A
waiver
under
this
subsection
shall
be
valid
from
29
the
date
the
department
grants
the
waiver
until
the
date
the
30
nursing
facility
renews
its
license
under
this
chapter.
A
31
nursing
facility
may
apply
to
extend
a
waiver
under
this
32
subsection
each
time
the
nursing
facility
applies
to
renew
its
33
license
under
this
chapter.
34
12.
a.
A
nursing
facility
shall
post
the
following
data
on
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a
daily
basis:
1
(1)
The
nursing
facility’s
name.
2
(2)
The
current
date.
3
(3)
The
total
number
and
the
actual
hours
worked
each
shift
4
by
the
following
categories
of
licensed
and
unlicensed
nursing
5
staff
directly
responsible
for
resident
care:
6
(a)
Registered
nurses.
7
(b)
Nurse
aides.
8
(4)
The
number
of
the
nursing
facility’s
residents.
9
b.
(1)
A
nursing
facility
shall
post
the
data
specified
in
10
paragraph
“a”
on
a
daily
basis
at
the
beginning
of
each
shift.
11
(2)
Data
must
be
posted
in
a
clear
and
readable
format
and
12
in
a
prominent
place
readily
accessible
to
residents,
staff,
13
and
visitors.
14
c.
A
nursing
facility
shall,
upon
oral
or
written
request,
15
make
the
data
specified
in
paragraph
“a”
available
to
the
public
16
for
review
at
a
reasonable
cost.
17
d.
A
nursing
facility
shall
maintain
the
data
specified
in
18
paragraph
“a”
for
a
minimum
of
eighteen
months.
19
13.
The
department
shall
adopt
rules
pursuant
to
chapter
17A
20
to
implement
this
section.
21
EXPLANATION
22
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
23
the
explanation’s
substance
by
the
members
of
the
general
assembly.
24
This
bill
relates
to
nursing
facility
(facility)
staffing
25
requirements.
26
The
bill
defines
“certified
nurse
aide
training
program”,
27
“nurse
aide”,
“physician”,
“registered
nurse”,
“resident
28
assessment”,
and
“resident
care
plan”.
29
The
bill
requires
facilities
to
have
sufficient
staff
with
30
the
appropriate
competencies
and
skill
sets
to
provide
nursing
31
care
and
related
services
to
ensure
resident
safety
and
attain
32
the
highest
practicable
physical,
mental,
and
psychosocial
33
well-being
of
each
resident,
as
determined
by
resident
34
assessments
and
individual
resident
care
plans
and
considering
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the
number,
acuity,
and
diagnoses
of
the
nursing
facility’s
1
residents.
2
The
bill
requires
facilities
to
provide
nursing
care
on
a
3
24-hour
basis
to
all
residents
in
accordance
with
each
resident
4
care
plan.
The
bill
details
the
types
of
employees
and
types
5
of
care
a
facility
must
provide.
6
The
bill
requires
facilities
to
provide
a
minimum
of
3.48
7
hours
per
resident
per
day
for
total
nurse
staffing,
including
8
a
minimum
of
0.55
hours
per
resident
per
day
for
registered
9
nurses
and
a
minimum
of
2.45
hours
per
resident
per
day
for
10
nurse
aides.
The
minimum
hours
requirements
are
not
to
be
11
construed
as
setting
minimum
staffing
levels.
12
The
bill
requires
facilities
to
have
a
registered
nurse
13
on
site
24
hours
per
day
that
is
available
to
provide
direct
14
resident
care.
If
the
department
of
inspections,
appeals,
15
and
licensing
(DIAL)
waives
the
requirement
for
an
on-site
16
registered
nurse
for
a
facility,
the
facility
must
have
a
17
registered
nurse,
physician
assistant,
or
physician
available
18
to
respond
immediately
to
telephone
calls
from
the
facility.
19
The
bill
requires
facilities
to
designate
a
registered
nurse
20
to
serve
as
the
director
of
nursing
on
a
full-time
basis.
The
21
director
of
nursing
may
serve
as
a
charge
nurse
only
when
the
22
nursing
facility
has
an
average
daily
occupancy
of
60
or
fewer
23
residents.
24
The
bill
requires
facilities
to
employ
or
contract
with
at
25
least
one
physician
that
will
evaluate
each
resident
for
wounds
26
and
infections
on
a
weekly
basis.
The
physician
shall
treat
27
or
recommend
a
treatment
for
each
of
a
resident’s
identified
28
wounds
and
infections.
29
The
bill
requires
facilities
to
ensure
that
nurse
aides
30
are
able
to
demonstrate
competency
in
skills
and
techniques
31
necessary
to
care
for
residents’
needs
as
identified
through
32
resident
assessments
and
described
in
each
resident
care
plan.
33
Before
employing
an
individual
as
a
nurse
aide,
a
facility
34
must
verify
that
the
individual
has
met
competency
evaluation
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requirements
unless
the
individual
is
a
full-time
employee
in
a
1
training
and
competency
evaluation
program,
or
the
individual
2
can
prove
that
they
recently
completed
a
certified
nurse
aide
3
training
program
and
have
not
yet
been
included
in
DIAL’s
nurse
4
aide
registry.
The
facility
must
ensure
that
the
individual
5
actually
becomes
included
in
the
nurse
aide
registry.
6
Before
employing
an
individual
as
a
nurse
aide,
the
7
bill
requires
a
facility
to
obtain
information
from
every
8
state
registry
established
under
section
1819(e)(2)(A)
or
9
1919(e)(2)(A)
of
the
federal
Social
Security
Act
that
the
10
facility
has
reason
to
believe
will
include
information
on
the
11
individual.
12
The
bill
requires
an
individual
to
complete
another
training
13
and
competency
evaluation
program
if
the
individual
has
14
not
provided
nursing
care
or
related
services
for
monetary
15
compensation
for
the
most
recent
24
consecutive
months.
16
The
bill
requires
facilities
to
conduct
a
performance
review
17
of
every
nurse
aide
at
least
once
every
12
months,
and
provide
18
regular
in-service
education
based
on
the
outcome
of
these
19
reviews.
In-service
training
must
comply
with
the
requirements
20
of
42
C.F.R.
§483.95(g).
21
The
bill
authorizes
DIAL
to
waive
the
certain
staffing
and
22
hours
of
care
per
resident
per
day
requirements
for
a
facility
23
if
the
facility
demonstrates
certain
conditions
exist.
The
24
bill
details
a
facility’s
duties
and
DIAL’s
duties
related
25
to
such
waivers.
The
bill
details
when
a
facility
is
not
26
eligible
for
a
waiver
due
to
hardship.
A
facility
may
apply
to
27
extend
a
waiver
due
to
hardship
each
time
the
facility
renews
28
its
license.
All
other
waivers
are
subject
to
DIAL’s
annual
29
review.
30
The
bill
requires
facilities
to
post
data
detailed
in
the
31
bill
on
a
daily
basis
at
the
beginning
of
each
shift,
in
a
32
clear
and
readable
format,
and
in
a
prominent
place
readily
33
accessible
to
residents,
staff,
and
visitors.
Facilities
34
must,
upon
oral
or
written
request,
make
the
data
available
to
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the
public
for
review
at
a
reasonable
cost.
Facilities
must
1
maintain
the
posted
data
for
a
minimum
of
18
months.
2
The
bill
directs
DIAL
to
adopt
administrative
rules
to
3
implement
the
bill.
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