2020 -- S 2519

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LC004596

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2020

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A N   A C T

RELATING TO HEALTH AND SAFETY -- NURSING HOME STAFFING AND QUALITY

CARE ACT

     

     Introduced By: Senators Goodwin, Ruggerio, McCaffrey, Euer, and Lawson

     Date Introduced: February 25, 2020

     Referred To: Senate Health & Human Services

     It is enacted by the General Assembly as follows:

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     SECTION 1. Chapter 23-17.5 of the General Laws entitled "Rights of Nursing Home

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Patients" is hereby amended by adding thereto the following sections:

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     23-17.5-32. Minimum staffing levels.

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     (a) Each facility shall have the necessary nursing service personnel (licensed and non-

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licensed) in sufficient numbers on a twenty-four (24) hour basis, to assess the needs of residents,

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to develop and implement resident care plans, to provide direct resident care services, and to

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perform other related activities to maintain the health, safety and welfare of residents. The facility

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shall have a registered nurse on the premises twenty-four (24) hours a day.

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     (b) For purposes of this section, the following definitions shall apply:

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     (1) "Direct caregiver" means a registered nurse, a licensed practical nurse, a medication

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technician, and a certified nurse assistant.

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     (2) "Hours of direct nursing care" means the actual hours of work performed per patient

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day by a direct caregiver.

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     (c) Commencing on October 1, 2020, nursing facilities shall provide a minimum daily

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average of four and one-tenth (4.1) hours of direct nursing care per resident, per day, of which at

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least two and eight-tenths (2.8) hours shall be provided by certified nurse assistants.

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     (d) Director of nursing hours and nursing staff hours spent on administrative duties or non-

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direct caregiving tasks are excluded and may not be counted toward compliance with the minimum

 

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staffing hours requirement in subsection (a) of this section.

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     (e) The minimum hours of direct nursing care requirements shall be minimum standards

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only. Nursing facilities shall employ and schedule additional staff as needed to ensure quality

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resident care based on the needs of individual residents and to ensure compliance with all relevant

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state and federal staffing requirements.

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     (f) The department shall promulgate rules and regulations to amend the Rhode Island code

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of regulations in consultation with stakeholders to implement these minimum staffing requirements

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on or before October 1, 2020.

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     (g) On or before January 1, 2023, and every five (5) years thereafter, the department shall

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consult with consumers, consumer advocates, recognized collective bargaining agents, and

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providers to determine the sufficiency of the staffing standards provided in this section and may

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promulgate rules and regulations to increase the minimum staffing ratios to adequate levels.

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     23-17.5-33. Minimum staffing level compliance and enforcement program.

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     (a) Compliance determination.

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     (1) The department shall submit proposed rules and regulations for adoption by January 1,

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2021 establishing a system for determining compliance with minimum staffing requirements set

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forth in § 23-17.5-32.

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     (2) Compliance shall be determined quarterly by comparing the number of hours provided

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per resident, per day using the Centers for Medicare and Medicaid Services' payroll-based journal

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and the facility's daily census, as self-reported by the facility to the department on a quarterly basis.

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     (3) The department shall use the quarterly payroll-based journal and the self-reported

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census to calculate the number of hours provided per resident, per day and compare this ratio to the

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minimum staffing standards required under § 23-17.5-32. Discrepancies between job titles

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contained in § 23-17.5-32 and the payroll-based journal shall be addressed by rules and regulations.

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     (b) Monetary penalties.

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     (1) The department shall submit proposed rules and regulations for adoption on or before

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January 1, 2021 establishing monetary penalties for facilities not in compliance with minimum

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staffing requirements set forth in § 23-17.5-32.

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     (2) No monetary penalty may be issued for noncompliance during the implementation

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period, which shall extend from October 1, 2020 through December 31, 2020. If a facility is found

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to be noncompliant during the implementation period, the department shall provide a written notice

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identifying the staffing deficiencies and require the facility to provide a sufficiently detailed

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correction plan to meet the statutory minimum staffing levels.

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     (3) Monetary penalties shall be imposed beginning on January 1, 2021 and quarterly

 

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thereafter and shall be based on the latest quarter for which the department has data.

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     (4) Monetary penalties shall be established based on a formula that calculates on a daily

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basis the cost of wages and benefits for the missing staffing hours.

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     (5) All notices of noncompliance shall include the computations used to determine

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noncompliance and establishing the variance between minimum staffing ratios and the department's

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computations.

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     (6) The penalty for the first offense shall be two hundred percent (200%) of the cost of

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wages and benefits for the missing staffing hours. The penalty shall increase to two hundred fifty

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percent (250%) of the cost of wages and benefits for the missing staffing hours for the second

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offense and three hundred percent (300%) the cost of wages and benefits for the missing staffing

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hours for the third and all subsequent offenses.

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     (7) For facilities that have an offense in three (3) consecutive quarters, EOHHS shall deny

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any further Medicaid Assistance payments with respect to all individuals entitled to benefits who

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are admitted to the facility on or after January 1, 2021.

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      (c)(1) The penalty shall be imposed regardless of whether the facility has committed other

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violations of this chapter during the same period that the staffing offense occurred.

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     (2) The penalty may not be waived except as provided in subsection (c)(3) of this section,

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but the department shall have the discretion to determine the gravity of the violation in situations

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where there is no more than a ten percent (10%) deviation from the staffing requirements and make

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appropriate adjustments to the penalty.

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     (3) The department is granted discretion to waive the penalty when unforeseen

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circumstances have occurred that resulted in call-offs of scheduled staff. This provision shall be

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applied no more than six (6) times per quarter.

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     (4) Nothing in this section diminishes a facility's right to appeal.

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     (d)(1) Beginning January 1, 2021, pursuant to rules and regulations established by the

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department, funds that are received from financial penalties shall be used for technical assistance

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or specialized direct care staff training.

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     (2) The assessment of a penalty does not supplant the state's investigation process or

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issuance of deficiencies or citations under title 23.

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     (3) A notice of penalty assessment shall be prominently posted in the nursing facility and

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included on the department's website.

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     23-17.5-34. Nursing staff posting requirements.

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     (a) Each nursing facility shall post its daily direct care nurse staff levels by shift in a public

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place within the nursing facility that is readily accessible to and visible by residents, employees

 

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and visitors. The posting shall be accurate to the actual number of direct care nursing staff on duty

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for each shift per day. The posting shall be in a format prescribed by the director, to include:

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     (1) The number of registered nurses, licensed practical nurses, certified nursing assistants,

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and medication technicians;

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     (2) The number of temporary, outside agency nursing staff;

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     (3) The resident census as of twelve o'clock (12:00) a.m.; and

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     (4) Documentation of the use of unpaid eating assistants (if utilized by the nursing facility

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on that date).

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     (b) The posting information shall be maintained on file by the nursing facility for no less

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than three (3) years and shall be made available to the public upon request.

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     (c) Each nursing facility shall report the information compiled pursuant to section (a) of

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this section and in accordance with department of health regulations to the department of health on

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a monthly basis in an electronic format prescribed by the director. The director shall make this

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information available to the public on a quarterly basis on the department of health website,

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accompanied by a written explanation to assist members of the public in interpreting the

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information reported pursuant to this section.

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     (d) In addition to the daily direct nurse staffing level reports, each nursing facility shall

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post the following information in a legible format and in a conspicuous place readily accessible to

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and visible by residents, employees and visitors of the nursing facility:

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     (1) The minimum number of nursing facility direct care staff per shift that is required to

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comply with the minimum staffing level requirements in § 23-17.5-32; and

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     (2) The telephone number or Internet website that a resident, employee or visitor of the

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nursing facility may use to report a suspected violation by the nursing facility of a regulatory

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requirement concerning staffing levels and direct patient care.

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     (e) No nursing facility shall discharge or in any manner discriminate or retaliate against

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any resident of any nursing facility, or any relative, guardian, conservator or sponsoring agency

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thereof or against any employee of any nursing facility or against any other person because the

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resident, relative, guardian, conservator, sponsoring agency, employee or other person has filed any

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complaint or instituted or caused to be instituted any proceeding under this chapter, or has testified

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or is about to testify in any such proceeding or because of the exercise by the resident, relative,

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guardian, conservator, sponsoring agency, employee or other person on behalf of himself, herself

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or others of any right afforded by §§ 23-17.5-32, 23-17.5-33 and 23-17.5-34. Notwithstanding any

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other provision of law to the contrary, any nursing facility that violates any provision of this section

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shall:

 

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     (1) Be liable to the injured party for treble damages; and

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     (2)(i) Reinstate the employee, if the employee was terminated from employment in

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violation of any provision of this section, or

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     (ii) Restore the resident to his or her living situation prior to such discrimination or

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retaliation, including his or her housing arrangement or other living conditions within the nursing

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facility, as appropriate, if the resident's living situation was changed in violation of any provision

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of this section. For purposes of this section, "discriminate or retaliate" includes, but is not limited

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to, the discharge, demotion, suspension or any other detrimental change in terms or conditions of

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employment or residency, or the threat of any such action.

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     (f)(1) The nursing facility shall prepare an annual report showing the average daily direct

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care nurse staffing level for the nursing facility by shift and by category of nurse to include:

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     (i) Registered nurses;

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     (ii) Licensed practical nurses;

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     (iii) Certified nursing assistants and medication technicians;

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     (iv) The use of registered and licensed practical nurses and certified nursing assistant staff

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from temporary placement agencies; and

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     (v) The nurses and certified nurse assistant turnover rates.

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     (2) The annual report shall be submitted with the nursing facility's renewal application and

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provide data for the previous twelve (12) months and ending on or after September 30th, for the

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year preceding the license renewal year. Annual reports shall be submitted in a format prescribed

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by the director.

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     (g) The information on nurse staffing shall be reviewed as part of the nursing facility's

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annual licensing survey and shall be available to the public, both in printed form and on the

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department's website, by nursing facility.

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     (h) The director of nurses may act as a charge nurse only when the nursing facility is

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licensed for thirty (30) beds or less.

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     (i) Whenever the licensing agency determines, in the course of inspecting a nursing facility,

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that additional staffing is necessary on any residential area to provide adequate nursing care and

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treatment or to ensure the safety of residents, the licensing agency may require the nursing facility

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to provide such additional staffing and any or all of the following actions shall be taken to enforce

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compliance with the determination of the licensing agency:

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     (1) The nursing facility shall be cited for a deficiency and shall be required to augment its

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staff within ten (10) days in accordance with the determination of the licensing agency;

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     (2) If failure to augment staffing is cited, the nursing facility shall be required to curtail

 

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admission to the nursing facility;

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     (3) If a continued failure to augment staffing is cited, the nursing facility shall be subjected

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to an immediate compliance order to increase the staffing, in accordance with § 23-1- 21; or

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     (4) The sequence and inclusion or non-inclusion of the specific sanctions may be modified

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in accordance with the severity of the deficiency in terms of its impact on the quality of resident

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care.

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     (j) No nursing staff of any nursing facility shall be regularly scheduled for double shifts.

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     (k) A nursing facility that fails to comply with the provisions of this chapter, or any rules

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or regulations adopted pursuant thereto, shall be subject to a penalty as determined by the

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department .

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     23-17.5-35. Staffing plan.

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     (a) There shall be a master plan of the staffing pattern for providing twenty-four (24) hour

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direct care nursing service; for the distribution of direct care nursing personnel for each floor and/or

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residential area; for the replacement of direct care nursing personnel; and for forecasting future

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needs.

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     (1) The staffing pattern shall include provisions for registered nurses, licensed practical

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nurses, certified nursing assistants, and medication technicians and other personnel as required.

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     (2) The number and type of nursing personnel shall be based on resident care needs and

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classifications as determined for each residential area. Each nursing facility shall be responsible to

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have sufficient qualified staff to meet the needs of the residents.

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     (3) At least one individual who is certified in basic life support must be available

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twenty­four (24) hours a day within the nursing facility.

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     (4) Each nursing facility shall include direct caregivers, including at least one certified

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nursing assistant, in the process to create the master plan of the staffing pattern and the federally

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mandated facility assessment. If the certified nursing assistants in the nursing facility are

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represented under a collective bargaining agreement, the bargaining unit shall coordinate voting to

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allow the certified nursing assistants to select their representative.

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     23-17.5-36. Enhanced training.

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     The general assembly shall appropriate the sum of six hundred thousand dollars ($600,000)

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for use by the department of labor and training for the issuance of grants to eligible nursing facilities

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for enhanced training for direct care and support services staff to improve resident quality of care

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and address the changing health care needs of nursing facility residents due to higher acuity and

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increased cognitive impairments. The department will work with stakeholders, including labor

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representatives, to create the eligibility criteria for the grants. In order for facilities to be eligible

 

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they must pay their employees at least fifteen dollars ($15.00) per hour, have staff retention above

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the statewide median, and comply with the minimum staffing requirements.

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     SECTION 2. Section 40-8-19 of the General Laws in Chapter 40-8 entitled "Medical

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Assistance" is hereby amended to read as follows:

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     40-8-19. Rates of payment to nursing facilities.

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     (a) Rate reform.

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     (1) The rates to be paid by the state to nursing facilities licensed pursuant to chapter 17 of

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title 23, and certified to participate in Title XIX of the Social Security Act for services rendered to

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Medicaid-eligible residents, shall be reasonable and adequate to meet the costs that must be

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incurred by efficiently and economically operated facilities in accordance with 42 U.S.C. §

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1396a(a)(13). The executive office of health and human services ("executive office") shall

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promulgate or modify the principles of reimbursement for nursing facilities in effect as of July 1,

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2011, to be consistent with the provisions of this section and Title XIX, 42 U.S.C. § 1396 et seq.,

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of the Social Security Act.

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     (2) The executive office shall review the current methodology for providing Medicaid

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payments to nursing facilities, including other long-term-care services providers, and is authorized

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to modify the principles of reimbursement to replace the current cost-based methodology rates with

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rates based on a price-based methodology to be paid to all facilities with recognition of the acuity

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of patients and the relative Medicaid occupancy, and to include the following elements to be

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developed by the executive office:

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     (i) A direct-care rate adjusted for resident acuity;

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     (ii) An indirect-care rate comprised of a base per diem for all facilities;

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     (iii) A rearray of costs for all facilities every three (3) years beginning October, 2015, that

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may or may not result in automatic per diem revisions;

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     (iv) Application of a fair-rental value system;

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     (v) Application of a pass-through system; and

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     (vi) Adjustment of rates by the change in a recognized national nursing home inflation

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index to be applied on October 1 of each year, beginning October 1, 2012. This adjustment will not

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occur on October 1, 2013, October 1, 2014, or October 1, 2015, but will occur on April 1, 2015.

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The adjustment of rates will also not occur on October 1, 2017, October 1, 2018, and October 1,

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2019. Effective July 1, 2018, rates paid to nursing facilities from the rates approved by the Centers

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for Medicare and Medicaid Services and in effect on October 1, 2017, both fee-for-service and

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managed care, will be increased by one and one-half percent (1.5%) and further increased by one

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percent (1%) on October 1, 2018, and further increased by one percent (1%) on October 1, 2019.

 

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The inflation index shall be applied without regard for the transition factors in subsections (b)(1)

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and (b)(2). For purposes of October 1, 2016, adjustment only, any rate increase that results from

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application of the inflation index to subsections (a)(2)(i) and (a)(2)(ii) shall be dedicated to increase

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compensation for direct-care workers in the following manner: Not less than 85% of this aggregate

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amount shall be expended to fund an increase in wages, benefits, or related employer costs of direct-

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care staff of nursing homes. For purposes of this section, direct-care staff shall include registered

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nurses (RNs), licensed practical nurses (LPNs), certified nursing assistants (CNAs), certified

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medical technicians, housekeeping staff, laundry staff, dietary staff, or other similar employees

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providing direct-care services; provided, however, that this definition of direct-care staff shall not

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include: (i) RNs and LPNs who are classified as "exempt employees" under the Federal Fair Labor

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Standards Act (29 U.S.C. § 201 et seq.); or (ii) CNAs, certified medical technicians, RNs, or LPNs

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who are contracted, or subcontracted, through a third-party vendor or staffing agency. By July 31,

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2017, nursing facilities shall submit to the secretary, or designee, a certification that they have

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complied with the provisions of this subsection (a)(2)(vi) with respect to the inflation index applied

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on October 1, 2016. Any facility that does not comply with terms of such certification shall be

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subjected to a clawback, paid by the nursing facility to the state, in the amount of increased

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reimbursement subject to this provision that was not expended in compliance with that certification.

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     (3) Commencing on October 1,2020, any rate increase that results from application of the

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inflation index to subsections (a)(2)(i) and (a)(2)(ii) of this section or any other rate increase shall

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be dedicated to increase compensation for all eligible direct-care workers in the following manner

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on October 1, of each year. For purposes of this subsection, compensation increases are limited to

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base salary or hourly wage increases and associated payroll tax increases for eligible direct-care

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workers. This application of the inflation index shall apply for Medicaid reimbursement in nursing

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facilities for both managed care and fee-for-service. For purposes of this subsection, direct-care

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staff shall include registered nurses (RNs), licensed practical nurses (LPNs), certified nursing

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assistants (CNAs), certified medication technicians, housekeeping staff, laundry staff, dietary staff

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or other similar employees providing direct-care services; provided, however that this definition of

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direct-care staff shall not include:

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     (i) RNs and LPNs who are classified as "exempt employees" under the federal Fair Labor

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Standards Act (29 U.S.C. § 201 et seq.); or

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     (ii) CNAs, certified medication technicians, RNs or LPNs who are contracted or

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subcontracted through a third-party vendor or staffing agency.

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     (4)(i) By July 31, 2020, and July 31 of each year thereafter, nursing facilities shall submit

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to the secretary or designee a certification that they have complied with the provisions of subsection

 

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(a)(2)(vii) of this section with respect to the inflation index applied on October 1. The executive

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office of health and human services (EOHHS) shall create the certification form which nursing

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facilities must complete with information on how each individual eligible employee's compensation

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increased, including information regarding hourly wages prior to the increase and after the

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compensation increase, hours paid after the compensation increase and associated increased payroll

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taxes. A collective bargaining agreement can be used in lieu of the certification form for represented

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employees. All data reported on the compliance form is subject to review and audit by EOHHS.

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The audits may include field or desk audits, and facilities may be required to provide additional

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supporting documents including, but not limited to, payroll records.

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     (ii) Any facility that does not comply with the terms of certification shall be subjected to a

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clawback and twenty-five percent (25%) penalty of the unspent or impermissibly spent funds, paid

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by the nursing facility to the state, in the amount of increased reimbursement subject to this

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provision that was not expended in compliance with that certification.

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     (b) Transition to full implementation of rate reform. For no less than four (4) years after

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the initial application of the price-based methodology described in subsection (a)(2) to payment

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rates, the executive office of health and human services shall implement a transition plan to

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moderate the impact of the rate reform on individual nursing facilities. Said transition shall include

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the following components:

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     (1) No nursing facility shall receive reimbursement for direct-care costs that is less than

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the rate of reimbursement for direct-care costs received under the methodology in effect at the time

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of passage of this act; for the year beginning October 1, 2017, the reimbursement for direct-care

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costs under this provision will be phased out in twenty-five-percent (25%) increments each year

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until October 1, 2021, when the reimbursement will no longer be in effect; and

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     (2) No facility shall lose or gain more than five dollars ($5.00) in its total, per diem rate the

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first year of the transition. An adjustment to the per diem loss or gain may be phased out by twenty-

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five percent (25%) each year; except, however, for the years beginning October 1, 2015, there shall

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be no adjustment to the per diem gain or loss, but the phase out shall resume thereafter; and

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     (3) The transition plan and/or period may be modified upon full implementation of facility

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per diem rate increases for quality of care-related measures. Said modifications shall be submitted

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in a report to the general assembly at least six (6) months prior to implementation.

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     (4) Notwithstanding any law to the contrary, for the twelve-month (12) period beginning

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July 1, 2015, Medicaid payment rates for nursing facilities established pursuant to this section shall

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not exceed ninety-eight percent (98%) of the rates in effect on April 1, 2015. Consistent with the

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other provisions of this chapter, nothing in this provision shall require the executive office to restore

 

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the rates to those in effect on April 1, 2015, at the end of this twelve-month (12) period.

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     SECTION 3. This act shall take effect upon passage.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO HEALTH AND SAFETY -- NURSING HOME STAFFING AND QUALITY

CARE ACT

***

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     This act would mandate minimum staffing levels and standards for quality care for nursing

2

homes and their residents with violations subject to monetary penalties, appropriate six hundred

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thousand dollars ($600,000) for enhanced training to provide care for residents with increased

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cognitive impairments and provide wage increases subject to the rate of inflation.

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     This act would take effect upon passage.

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