To amend title XVIII of the Social Security Act to impose minimum nurse staffing ratios in Medicare participating hospitals, and for other purposes.

Summary: Quality Nursing Care Act of 2004 - Amends title XVIII (Medicare) of the Social Security Act, as amended by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, to require under new Medicare part D (Voluntary Prescription Drug Benefit Program) that each participating hospital adopt and implement a staffing system that ensures a number of registered nurses on each shift and in each unit of the hospital to ensure appropriate staffing levels for patient care. Outlines whistle-blower protections.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Quality Nursing Care Act of 2004''.

SEC. 2. FINDINGS.

    The Congress makes the following findings:
            (1) There are hospitals throughout the United States that 
        have inadequate staffing of registered nurses to protect the 
        well-being and health of the patients.
            (2) Studies show that the health of patients in hospitals 
        is directly proportionate to the number of registered nurses 
        working in the hospital.
            (3) There is a critical shortage of registered nurses in 
        the United States.
            (4) The effect of that shortage is revealed in unsafe 
        staffing levels in hospitals.
            (5) Patient safety is adversely affected by these unsafe 
        staffing levels, creating a public health crisis.
            (6) Registered nurses are being required to perform 
        professional services under conditions that do not support 
        quality health care or a healthful work environment for 
        registered nurses.
            (7) As a payer for inpatient and outpatient hospital 
        services for individuals entitled to benefits under the program 
        established under title XVIII of the Social Security Act, the 
        Federal Government has a compelling interest in promoting the 
        safety of such individuals by requiring any hospital 
        participating in such program to establish minimum safe 
        staffing levels for registered nurses.

SEC. 3. ESTABLISHMENT OF MINIMUM STAFFING RATIOS BY MEDICARE 
              PARTICIPATING HOSPITALS.

    (a) Requirement of Medicare Provider Agreement.--Section 1866(a)(1) 
of the Social Security Act (42 U.S.C. 1395cc(a)(1)), as amended by the 
Medicare Prescription Drug, Improvement, and Modernization Act of 2003, 
is amended--
            (1) by striking ``and'' at the end of subparagraph (U);
            (2) by striking the period at the end of subparagraph (V) 
        and inserting ``, and''; and
            (3) by inserting after subparagraph (V) and before the end 
        matter the following:
                    ``(W) in the case of a hospital--
                            ``(i) to adopt and implement a staffing 
                        system that meets the requirements of section 
                        1898;
                            ``(ii) to meet the requirements of such 
                        section relating to--
                                    ``(I) records maintenance;
                                    ``(II) data collection; and
                                    ``(III) data submission; and
                            ``(iii) to meet the requirements of such 
                        section relating to non-discrimination and 
                        retaliation.''.
    (b) Requirements.--Part D of title XVIII of the Social Security 
Act, as amended by the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003, is amended by adding at the end the 
following:

      ``staffing requirements for medicare participating hospitals

    ``Sec. 1898. (a) Establishment of Staffing System.--Each 
participating hospital shall adopt and implement a staffing system that 
ensures a number of registered nurses on each shift and in each unit of 
the hospital to ensure appropriate staffing levels for patient care. A 
staffing system adopted and implemented under this section shall--
            ``(1) be developed on the basis of input from the direct 
        care-giving registered nurse staff or, where nurses are 
        represented, with the applicable recognized or certified 
        collective bargaining representatives of the registered nurses;
            ``(2) be based upon the number of patients and the level 
        and variability of intensity of care to be provided, with 
        appropriate consideration given to admissions, discharges and 
        transfers during each shift;
            ``(3) account for contextual issues affecting staffing and 
        the delivery of care, including architecture and geography of 
        the environment and available technology;
            ``(4) reflect the level of preparation and experience of 
        those providing care;
            ``(5) account for staffing level effectiveness or 
        deficiencies in related health care classifications, including 
        but not limited to, certified nurse assistants, licensed 
        vocational nurses, licensed psychiatric technicians, nursing 
        assistants, aides and orderlies;
            ``(6) reflect staffing levels recommended by specialty 
        nursing organizations;
            ``(7) subject to subsection (b), establish upwardly 
        adjustable registered nurse-to-patient ratios based upon 
        registered nurses' assessment of patient acuity and existing 
        conditions;
            ``(8) provide that a registered nurse shall not be assigned 
        to work in a particular unit without first having established 
        the ability to provide professional care in such unit; and
            ``(9) be based on methods that assure validity and 
        reliability.
    ``(b) Limitation.--A staffing system adopted and implemented 
pursuant to subsection (a) may not--
            ``(1) set registered-nurse levels below those required by 
        any Federal or State law or regulation; or
            ``(2) utilize any minimum registered nurse-to-patient ratio 
        established pursuant to subsection (a)(7) as an upper limit on 
        the staffing of the hospital to which such ratio applies.
    ``(c) Reporting, and Release to Public, of Certain Staffing 
Information.--
            ``(1) Requirements for hospitals.--Each participating 
        hospital shall--
                    ``(A) post daily for each shift, in a clearly 
                visible place, a document that specifies in a uniform 
                manner (as prescribed by the Secretary) the current 
                number of licensed and unlicensed nursing staff 
                directly responsible for patient care in each unit of 
                the hospital, identifying specifically the number of 
                registered nurses;
                    ``(B) upon request, make available to the public--
                            ``(i) the nursing staff information 
                        described in subparagraph (A); and
                            ``(ii) a detailed written description of 
                        the staffing system established by the hospital 
                        pursuant to subsection (a); and
                    ``(C) submit to the Secretary in a uniform manner 
                (as prescribed by the Secretary) the nursing staff 
                information described in subparagraph (A) through 
                electronic data submission not less frequently than 
                quarterly.
            ``(2) Secretarial responsibilities.--The Secretary shall--
                    ``(A) make the information submitted pursuant to 
                paragraph (1)(C) publicly available, including by 
                publication of such information on the Internet site of 
                the Department of Health and Human Services; and
                    ``(B) provide for the auditing of such information 
                for accuracy as a part of the process of determining 
                whether an institution is a hospital for purposes of 
                this title.
    ``(d) Record-Keeping; Data Collection; Evaluation.--
            ``(1) Record-keeping.--Each participating hospital shall 
        maintain for a period of at least 3 years (or, if longer, until 
        the conclusion of pending enforcement activities) such records 
        as the Secretary deems necessary to determine to whether the 
        hospital has adopted and implemented a staffing system pursuant 
        to subsection (a).
            ``(2) Data collection on certain outcomes.--The Secretary 
        shall require the collection, maintenance, and submission of 
        data by each participating hospital sufficient to establish the 
        link between the staffing system established pursuant to 
        subsection (a) and--
                    ``(A) patient acuity from maintenance of acuity 
                data through entries on patients' charts;
                    ``(B) patient outcomes that are nursing sensitive, 
                such as patient falls, adverse drug events, injuries to 
                patients, skin breakdown, pneumonia, infection rates, 
                upper gastrointestinal bleeding, shock, cardiac arrest, 
                length of stay, and patient re-admissions;
                    ``(C) operational outcomes, such as work-related 
                injury or illness, vacancy and turnover rates, nursing 
                care hours per patient day, on-call use, overtime 
                rates, and needle-stick injuries; and
                    ``(D) patient complaints related to staffing 
                levels.
            ``(3) Evaluation.--Each participating hospital shall 
        annually evaluate its staffing system and established minimum 
        registered nurse staffing ratios to assure on-going reliability 
        and validity of the system and ratios. The evaluation shall be 
        conducted by a joint management-staff committee comprised of at 
        least 50 percent of registered nurses who provide direct 
        patient care and where nurses are represented, with the 
        involvement of the applicable recognized or certified 
        collective bargaining representatives of the registered nurses.
    ``(e) Enforcement.--
            ``(1) Responsibility.--The Secretary shall enforce the 
        requirements and prohibitions of this section.
            ``(2) Procedures for receiving and investigating 
        complaints.--The Secretary shall establish procedures under 
        which--
                    ``(A) any person may file a complaint that a 
                participating hospital has violated a requirement or a 
                prohibition of this section; and
                    ``(B) such complaints are investigated by the 
                Secretary.
            ``(3) Remedies.--If the Secretary determines that a 
        participating hospital has violated a requirement of this 
        section, the Secretary--
                    ``(A) shall require the facility to establish a 
                corrective action plan to prevent the recurrence of 
                such violation; and
                    ``(B) may impose civil money penalties under 
                paragraph (4).
            ``(4) Civil money penalties.--
                    ``(A) In general.--In addition to any other 
                penalties prescribed by law, the Secretary may impose a 
                civil money penalty of not more than $10,000 for each 
                knowing violation of a requirement of this section, 
                except that the Secretary shall impose a civil money 
                penalty of more than $10,000 for each such violation in 
                the case of a participating hospital that the Secretary 
                determines has a pattern or practice of such violations 
                (with the amount of such additional penalties being 
                determined in accordance with a schedule or methodology 
                specified in regulations).
                    ``(B) Procedures.--The provisions of section 1128A 
                (other than subsections (a) and (b)) shall apply to a 
                civil money penalty under this paragraph in the same 
                manner as such provisions apply to a penalty or 
                proceeding under section 1128A.
                    ``(C) Public notice of violations.--
                            ``(i) Internet site.--The Secretary shall 
                        publish on the Internet site of the Department 
of Health and Human Services the names of participating hospitals on 
which civil money penalties have been imposed under this section, the 
violation for which the penalty was imposed, and such additional 
information as the Secretary determines appropriate.
                            ``(ii) Change of ownership.--With respect 
                        to a participating hospital that had a change 
                        in ownership, as determined by the Secretary, 
                        penalties imposed on the hospital while under 
                        previous ownership shall no longer be published 
                        by the Secretary of such Internet site after 
                        the 1-year period beginning on the date of 
                        change in ownership.
    ``(f) Whistle-Blower Protections.--
            ``(1) Prohibition of discrimination and retaliation.--A 
        participating hospital shall not discriminate or retaliate in 
        any manner against any patient or employee of the hospital 
        because that patient or employee, or any other person, has 
        presented a grievance or complaint, or has initiated or 
        cooperated in any investigation or proceeding of any kind, 
        relating to the staffing system or other requirements and 
        prohibitions of this section.
            ``(2) Relief for prevailing employees.--An employee of a 
        participating hospital who has been discriminated or retaliated 
        against in employment in violation of this subsection may 
        initiate judicial action in a United States District Court and 
        shall be entitled to reinstatement, reimbursement for lost 
        wages and work benefits caused by the unlawful acts of the 
        employing hospital. Prevailing employees are entitled to 
        reasonable attorney's fees and costs associated with pursuing 
        the case.
            ``(3) Relief for prevailing patients.--A patient who has 
        been discriminated or retaliated against in violation of this 
        subsection may initiate judicial action in a United States 
        District Court. A prevailing patient shall be entitled to 
        liquidated damages of $5,000 for a violation of this statute in 
        addition to any other damages under other applicable statutes, 
        regulations or common law. Prevailing patients are entitled to 
        reasonable attorney's fees and costs associated with pursuing 
        the case.
            ``(4) Limitation on actions.--No action may be brought 
        under paragraph (2) or (3) more than 2 years after the 
        discrimination or retaliation with respect to which the action 
        is brought.
            ``(5) Treatment of adverse employment actions.--For 
        purposes of this subsection--
                    ``(A) an adverse employment action shall be treated 
                as `retaliation or discrimination'; and
                    ``(B) an adverse employment action includes--
                            ``(i) the failure to promote an individual 
                        or provide any other employment-related benefit 
                        for which the individual would otherwise be 
                        eligible;
                            ``(ii) an adverse evaluation or decision 
                        made in relation to accreditation, 
                        certification, credentialing, or licensing of 
                        the individual; and
                            ``(iii) a personnel action that is adverse 
                        to the individual concerned.
    ``(g) Rules of Construction.--
            ``(1) Relationship to state laws.--Nothing in this section 
        shall be construed as exempting or relieving any person from 
        any liability, duty, penalty, or punishment provided by any 
        present or future law of any State or political subdivision of 
        a State, other than any such law which purports to require or 
        permit the doing of any act which would be an unlawful practice 
        under this title.
            ``(2) Relationship to conduct prohibited under the national 
        labor relations act.--Nothing in this section shall be 
        construed as permitting conduct prohibited under the National 
        Labor Relations Act or under any other federal, State, or local 
        collective bargaining law.
    ``(h) Regulations.--The Secretary shall promulgate such regulations 
as are appropriate and necessary to implement this Act.
    ``(i) Definitions.--For purposes of this section--
            ``(1) the term `participating hospital' means a hospital 
        that has entered into a provider agreement under section 1866;
            ``(2) the term `registered nurse' means an individual who 
        has been granted a license to practice as a registered nurse in 
        at least one State;
            ``(3) the term `unit' of a hospital is an organizational 
        department or separate geographic area of a hospital, such as a 
        burn unit, a labor and delivery room, a post-anesthesia service 
        area, an emergency department, an operating room, a pediatric 
        unit, a step-down or intermediate care unit, a specialty care 
        unit, a telemetry unit, a general medical care unit, a subacute 
        care unit, and a transitional inpatient care unit;
            ``(4) a `shift' is a scheduled set of hours or duty period 
        to be worked at a participating hospital; and
            ``(5) a `person' includes one or more individuals, 
        associations, corporations, unincorporated organizations or 
        labor unions.''.
    (c) Effective Date.--The amendments made by this section shall 
become effective on January 1, 2005.