S.F. 527 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. 35 -1- LSB 1483XS (3) 91 dg/ko 1/ 11

S.F. 527 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. 35 -2- LSB 1483XS (3) 91 dg/ko 2/ 11

S.F. 527 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 35 -3- LSB 1483XS (3) 91 dg/ko 3/ 11

S.F. 527 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. 35 -4- LSB 1483XS (3) 91 dg/ko 4/ 11

S.F. 527 (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 35 -5- LSB 1483XS (3) 91 dg/ko 5/ 11

S.F. 527 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 35 -6- LSB 1483XS (3) 91 dg/ko 6/ 11

S.F. 527 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 35 -7- LSB 1483XS (3) 91 dg/ko 7/ 11

S.F. 527 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 35 -8- LSB 1483XS (3) 91 dg/ko 8/ 11

S.F. 527 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 35 -9- LSB 1483XS (3) 91 dg/ko 9/ 11

S.F. 527 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 35 -10- LSB 1483XS (3) 91 dg/ko 10/ 11