I 

108TH CONGRESS 

1ST SESSION H. R. 3656

To amend title XVIII of the Social Security Act to impose minimum nurse 

staffing ratios in Medicare participating hospitals, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

DECEMBER 8, 2003

Mrs. CAPPS introduced the following bill; which was referred to the Committee 

on Energy and Commerce, and in addition to the Committee on Ways 

and Means, for a period to be subsequently determined by the Speaker, 

in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL

To amend title XVIII of the Social Security Act to impose 

minimum nurse staffing ratios in Medicare participating 

hospitals, and for other purposes.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Quality Nursing Care 

5 Act of 2004’’. 

6 SEC. 2. FINDINGS. 

7 The Congress makes the following findings: 
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1 (1) There are hospitals throughout the United 

2 States that have inadequate staffing of registered 

3 nurses to protect the well-being and health of the 

4 patients. 

5 (2) Studies show that the health of patients in 

6 hospitals is directly proportionate to the number of 

7 registered nurses working in the hospital. 

8 (3) There is a critical shortage of registered 

9 nurses in the United States. 

10 (4) The effect of that shortage is revealed in 

11 unsafe staffing levels in hospitals. 

12 (5) Patient safety is adversely affected by these 

13 unsafe staffing levels, creating a public health crisis. 

14 (6) Registered nurses are being required to per15 form professional services under conditions that do 

16 not support quality health care or a healthful work 

17 environment for registered nurses. 

18 (7) As a payer for inpatient and outpatient hos19 pital services for individuals entitled to benefits 

20 under the program established under title XVIII of 

21 the Social Security Act, the Federal Government has 

22 a compelling interest in promoting the safety of such 

23 individuals by requiring any hospital participating in 

24 such program to establish minimum safe staffing 

25 levels for registered nurses. 
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1 SEC. 3. ESTABLISHMENT OF MINIMUM STAFFING RATIOS 

2 BY MEDICARE PARTICIPATING HOSPITALS. 

3 (a) REQUIREMENT OF MEDICARE PROVIDER AGREE4 MENT.—Section 1866(a)(1) of the Social Security Act (42 

5 U.S.C. 1395cc(a)(1)), as amended by the Medicare Pre6 scription Drug, Improvement, and Modernization Act of 

7 2003, is amended—

8 (1) by striking ‘‘and’’ at the end of subpara9 graph (U); 

10 (2) by striking the period at the end of sub11 paragraph (V) and inserting ‘‘, and’’; and 

12 (3) by inserting after subparagraph (V) and be13 fore the end matter the following: 

14 ‘‘(W) in the case of a hospital—

15 ‘‘(i) to adopt and implement a staffing 

16 system that meets the requirements of sec17 tion 1898; 

18 ‘‘(ii) to meet the requirements of such 

19 section relating to—

20 ‘‘(I) records maintenance; 

21 ‘‘(II) data collection; and 

22 ‘‘(III) data submission; and 

23 ‘‘(iii) to meet the requirements of 

24 such section relating to non-discrimination 

25 and retaliation.’’. 
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1 (b) REQUIREMENTS.—Part D of title XVIII of the 

2 Social Security Act, as amended by the Medicare Prescrip3 tion Drug, Improvement, and Modernization Act of 2003, 

4 is amended by adding at the end the following: 

5 ‘‘STAFFING REQUIREMENTS FOR MEDICARE

6 PARTICIPATING HOSPITALS

7 ‘‘SEC. 1898. (a) ESTABLISHMENT OF STAFFING SYS8 TEM.—Each participating hospital shall adopt and imple9 ment a staffing system that ensures a number of reg10 istered nurses on each shift and in each unit of the hos11 pital to ensure appropriate staffing levels for patient care. 

12 A staffing system adopted and implemented under this 

13 section shall—

14 ‘‘(1) be developed on the basis of input from 

15 the direct care-giving registered nurse staff or, 

16 where nurses are represented, with the applicable 

17 recognized or certified collective bargaining rep18 resentatives of the registered nurses; 

19 ‘‘(2) be based upon the number of patients and 

20 the level and variability of intensity of care to be 

21 provided, with appropriate consideration given to ad22 missions, discharges and transfers during each shift; 

23 ‘‘(3) account for contextual issues affecting 

24 staffing and the delivery of care, including architec25 ture and geography of the environment and available 

26 technology; 
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1 ‘‘(4) reflect the level of preparation and experi2 ence of those providing care; 

3 ‘‘(5) account for staffing level effectiveness or 

4 deficiencies in related health care classifications, in5 cluding but not limited to, certified nurse assistants, 

6 licensed vocational nurses, licensed psychiatric tech7 nicians, nursing assistants, aides and orderlies; 

8 ‘‘(6) reflect staffing levels recommended by spe9 cialty nursing organizations; 

10 ‘‘(7) subject to subsection (b), establish 

11 upwardly adjustable registered nurse-to-patient ra12 tios based upon registered nurses’ assessment of pa13 tient acuity and existing conditions; 

14 ‘‘(8) provide that a registered nurse shall not be 

15 assigned to work in a particular unit without first 

16 having established the ability to provide professional 

17 care in such unit; and 

18 ‘‘(9) be based on methods that assure validity 

19 and reliability. 

20 ‘‘(b) LIMITATION.—A staffing system adopted and 

21 implemented pursuant to subsection (a) may not—

22 ‘‘(1) set registered-nurse levels below those re23 quired by any Federal or State law or regulation; or 

24 ‘‘(2) utilize any minimum registered nurse-to25 patient ratio established pursuant to subsection 
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1 (a)(7) as an upper limit on the staffing of the hos2 pital to which such ratio applies. 

3 ‘‘(c) REPORTING, AND RELEASE TO PUBLIC, OF CER4 TAIN STAFFING INFORMATION.—

5 ‘‘(1) REQUIREMENTS FOR HOSPITALS.—Each 

6 participating hospital shall—

7 ‘‘(A) post daily for each shift, in a clearly 

8 visible place, a document that specifies in a uni9 form manner (as prescribed by the Secretary) 

10 the current number of licensed and unlicensed 

11 nursing staff directly responsible for patient 

12 care in each unit of the hospital, identifying 

13 specifically the number of registered nurses; 

14 ‘‘(B) upon request, make available to the 

15 public—

16 ‘‘(i) the nursing staff information de17 scribed in subparagraph (A); and 

18 ‘‘(ii) a detailed written description of 

19 the staffing system established by the hos20 pital pursuant to subsection (a); and 

21 ‘‘(C) submit to the Secretary in a uniform 

22 manner (as prescribed by the Secretary) the 

23 nursing staff information described in subpara24 graph (A) through electronic data submission 

25 not less frequently than quarterly. 
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1 ‘‘(2) SECRETARIAL RESPONSIBILITIES.—The 

2 Secretary shall—

3 ‘‘(A) make the information submitted pur4 suant to paragraph (1)(C) publicly available, in5 cluding by publication of such information on 

6 the Internet site of the Department of Health 

7 and Human Services; and 

8 ‘‘(B) provide for the auditing of such infor9 mation for accuracy as a part of the process of 

10 determining whether an institution is a hospital 

11 for purposes of this title. 

12 ‘‘(d) RECORD-KEEPING; DATA COLLECTION; EVAL13 UATION.—

14 ‘‘(1) RECORD-KEEPING.—Each participating 

15 hospital shall maintain for a period of at least 3 

16 years (or, if longer, until the conclusion of pending 

17 enforcement activities) such records as the Secretary 

18 deems necessary to determine to whether the hos19 pital has adopted and implemented a staffing system 

20 pursuant to subsection (a). 

21 ‘‘(2) DATA COLLECTION ON CERTAIN OUT22 COMES.—The Secretary shall require the collection, 

23 maintenance, and submission of data by each par24 ticipating hospital sufficient to establish the link be-
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1 tween the staffing system established pursuant to 

2 subsection (a) and—

3 ‘‘(A) patient acuity from maintenance of 

4 acuity data through entries on patients’ charts; 

5 ‘‘(B) patient outcomes that are nursing 

6 sensitive, such as patient falls, adverse drug 

7 events, injuries to patients, skin breakdown, 

8 pneumonia, infection rates, upper gastro9 intestinal bleeding, shock, cardiac arrest, length 

10 of stay, and patient re-admissions; 

11 ‘‘(C) operational outcomes, such as work12 related injury or illness, vacancy and turnover 

13 rates, nursing care hours per patient day, on14 call use, overtime rates, and needle-stick inju15 ries; and 

16 ‘‘(D) patient complaints related to staffing 

17 levels. 

18 ‘‘(3) EVALUATION.—Each participating hospital 

19 shall annually evaluate its staffing system and estab20 lished minimum registered nurse staffing ratios to 

21 assure on-going reliability and validity of the system 

22 and ratios. The evaluation shall be conducted by a 

23 joint management-staff committee comprised of at 

24 least 50 percent of registered nurses who provide di25 rect patient care and where nurses are represented, 
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1 with the involvement of the applicable recognized or 

2 certified collective bargaining representatives of the 

3 registered nurses. 

4 ‘‘(e) ENFORCEMENT.—

5 ‘‘(1) RESPONSIBILITY.—The Secretary shall en6 force the requirements and prohibitions of this sec7 tion. 

8 ‘‘(2) PROCEDURES FOR RECEIVING AND INVES9 TIGATING COMPLAINTS.—The Secretary shall estab10 lish procedures under which—

11 ‘‘(A) any person may file a complaint that 

12 a participating hospital has violated a require13 ment or a prohibition of this section; and 

14 ‘‘(B) such complaints are investigated by 

15 the Secretary. 

16 ‘‘(3) REMEDIES.—If the Secretary determines 

17 that a participating hospital has violated a require18 ment of this section, the Secretary—

19 ‘‘(A) shall require the facility to establish 

20 a corrective action plan to prevent the recur21 rence of such violation; and 

22 ‘‘(B) may impose civil money penalties 

23 under paragraph (4). 

24 ‘‘(4) CIVIL MONEY PENALTIES.—
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1 ‘‘(A) IN GENERAL.—In addition to any 

2 other penalties prescribed by law, the Secretary 

3 may impose a civil money penalty of not more 

4 than $10,000 for each knowing violation of a 

5 requirement of this section, except that the Sec6 retary shall impose a civil money penalty of 

7 more than $10,000 for each such violation in 

8 the case of a participating hospital that the 

9 Secretary determines has a pattern or practice 

10 of such violations (with the amount of such ad11 ditional penalties being determined in accord12 ance with a schedule or methodology specified 

13 in regulations). 

14 ‘‘(B) PROCEDURES.—The provisions of 

15 section 1128A (other than subsections (a) and 

16 (b)) shall apply to a civil money penalty under 

17 this paragraph in the same manner as such 

18 provisions apply to a penalty or proceeding 

19 under section 1128A. 

20 ‘‘(C) PUBLIC NOTICE OF VIOLATIONS.—

21 ‘‘(i) INTERNET SITE.—The Secretary 

22 shall publish on the Internet site of the

23 Department of Health and Human Serv24 ices the names of participating hospitals on 

25 which civil money penalties have been im-
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1 posed under this section, the violation for 

2 which the penalty was imposed, and such 

3 additional information as the Secretary de4 termines appropriate. 

5 ‘‘(ii) CHANGE OF OWNERSHIP.—With 

6 respect to a participating hospital that had 

7 a change in ownership, as determined by 

8 the Secretary, penalties imposed on the 

9 hospital while under previous ownership 

10 shall no longer be published by the Sec11 retary of such Internet site after the 1-

12 year period beginning on the date of 

13 change in ownership. 

14 ‘‘(f) WHISTLE-BLOWER PROTECTIONS.—

15 ‘‘(1) PROHIBITION OF DISCRIMINATION AND

16 RETALIATION.—A participating hospital shall not 

17 discriminate or retaliate in any manner against any 

18 patient or employee of the hospital because that pa19 tient or employee, or any other person, has pre20 sented a grievance or complaint, or has initiated or 

21 cooperated in any investigation or proceeding of any 

22 kind, relating to the staffing system or other re23 quirements and prohibitions of this section. 

24 ‘‘(2) RELIEF FOR PREVAILING EMPLOYEES.—

25 An employee of a participating hospital who has 
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1 been discriminated or retaliated against in employ2 ment in violation of this subsection may initiate judi3 cial action in a United States District Court and 

4 shall be entitled to reinstatement, reimbursement for 

5 lost wages and work benefits caused by the unlawful 

6 acts of the employing hospital. Prevailing employees 

7 are entitled to reasonable attorney’s fees and costs 

8 associated with pursuing the case. 

9 ‘‘(3) RELIEF FOR PREVAILING PATIENTS.—A 

10 patient who has been discriminated or retaliated 

11 against in violation of this subsection may initiate 

12 judicial action in a United States District Court. A 

13 prevailing patient shall be entitled to liquidated 

14 damages of $5,000 for a violation of this statute in 

15 addition to any other damages under other applica16 ble statutes, regulations or common law. Prevailing 

17 patients are entitled to reasonable attorney’s fees 

18 and costs associated with pursuing the case. 

19 ‘‘(4) LIMITATION ON ACTIONS.—No action may 

20 be brought under paragraph (2) or (3) more than 2 

21 years after the discrimination or retaliation with re22 spect to which the action is brought. 

23 ‘‘(5) TREATMENT OF ADVERSE EMPLOYMENT

24 ACTIONS.—For purposes of this subsection—
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1 ‘‘(A) an adverse employment action shall 

2 be treated as ‘retaliation or discrimination’; and 

3 ‘‘(B) an adverse employment action in4 cludes—

5 ‘‘(i) the failure to promote an indi6 vidual or provide any other employment-re7 lated benefit for which the individual would 

8 otherwise be eligible; 

9 ‘‘(ii) an adverse evaluation or decision 

10 made in relation to accreditation, certifi11 cation, credentialing, or licensing of the in12 dividual; and 

13 ‘‘(iii) a personnel action that is ad14 verse to the individual concerned. 

15 ‘‘(g) RULES OF CONSTRUCTION.—

16 ‘‘(1) RELATIONSHIP TO STATE LAWS.—Nothing 

17 in this section shall be construed as exempting or re18 lieving any person from any liability, duty, penalty, 

19 or punishment provided by any present or future law 

20 of any State or political subdivision of a State, other 

21 than any such law which purports to require or per22 mit the doing of any act which would be an unlawful 

23 practice under this title. 

24 ‘‘(2) RELATIONSHIP TO CONDUCT PROHIBITED

25 UNDER THE NATIONAL LABOR RELATIONS ACT.—
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1 Nothing in this section shall be construed as permit2 ting conduct prohibited under the National Labor 

3 Relations Act or under any other federal, State, or 

4 local collective bargaining law. 

5 ‘‘(h) REGULATIONS.—The Secretary shall promul6 gate such regulations as are appropriate and necessary to 

7 implement this Act. 

8 ‘‘(i) DEFINITIONS.—For purposes of this section—

9 ‘‘(1) the term ‘participating hospital’ means a 

10 hospital that has entered into a provider agreement 

11 under section 1866; 

12 ‘‘(2) the term ‘registered nurse’ means an indi13 vidual who has been granted a license to practice as 

14 a registered nurse in at least one State; 

15 ‘‘(3) the term ‘unit’ of a hospital is an organi16 zational department or separate geographic area of 

17 a hospital, such as a burn unit, a labor and delivery 

18 room, a post-anesthesia service area, an emergency 

19 department, an operating room, a pediatric unit, a 

20 step-down or intermediate care unit, a specialty care 

21 unit, a telemetry unit, a general medical care unit, 

22 a subacute care unit, and a transitional inpatient 

23 care unit; 

24 ‘‘(4) a ‘shift’ is a scheduled set of hours or duty 

25 period to be worked at a participating hospital; and 
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1 ‘‘(5) a ‘person’ includes one or more individ2 uals, associations, corporations, unincorporated or3 ganizations or labor unions.’’. 

4 (c) EFFECTIVE DATE.—The amendments made by 

5 this section shall become effective on January 1, 2005.

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