II 

115TH CONGRESS 

1ST SESSION S. 1063 

To amend the Public Health Service Act to establish direct care registered 

nurse-to-patient staffing ratio requirements in hospitals, and for other 

purposes. 

IN THE SENATE OF THE UNITED STATES 

MAY 4, 2017 

Mr. BROWN introduced the following bill; which was read twice and referred 

to the Committee on Health, Education, Labor, and Pensions 

A BILL 

To amend the Public Health Service Act to establish direct 

care registered nurse-to-patient staffing ratio requirements in 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; TABLE OF CONTENTS; FINDINGS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘Nurse Staffing Standards for Hospital Patient Safety 

6 and Quality Care Act of 2017’’. 

7 (b) TABLE OF CONTENTS.—The table of contents for 

8 this Act is as follows: 

Sec. 1. Short title; table of contents; findings. 

Sec. 2. Minimum direct care registered nurse staffing requirement. 


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Sec. 3. Enforcement of requirements through Federal programs. 

Sec. 4. Nurse workforce initiative. 

1 (c) FINDINGS.—Congress finds the following: 

2 (1) The Federal Government has a substantial 

3 interest in promoting quality care and improving the 

4 delivery of health care services to patients in health 

5 care facilities in the United States. 

6 (2) Recent changes in health care delivery sys7 tems that have resulted in higher acuity levels 

8 among patients in health care facilities increase the 

9 need for improved quality measures in order to pro10 tect patient care and reduce the incidence of medical 

11 errors. 

12 (3) Inadequate and poorly monitored registered 

13 nurse staffing practices that result in too few reg14 istered nurses providing direct care jeopardize the 

15 delivery of quality health care services. 

16 (4) Numerous studies have shown that patient 

17 outcomes are directly correlated to direct care reg18 istered nurse staffing levels, including a 2010 

19 Health Services Research study that concluded that 

20 implementation of minimum nurse-to-patient staff21 ing ratios in California has led to improved patient 

22 outcomes and nurse retention and a 2014 Agency 

23 for Healthcare Research and Quality study that con24 cluded increases in nurse staffing and skill mix lead 


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1 to improved quality and reduced length of stay at no 

2 additional cost. 

3 (5) Requirements for direct care registered 

4 nurse staffing ratios will help address the registered 

5 nurse shortage in the United States by aiding in re6 cruitment of new registered nurses and improving 

7 retention of registered nurses who are considering 

8 leaving direct patient care because of demands cre9 ated by inadequate staffing. 

10 (6) Establishing adequate minimum direct care 

11 registered nurse-to-patient ratios that take into ac12 count patient acuity measures will improve the deliv13 ery of quality health care services and guarantee pa14 tient safety. 

15 (7) Establishing safe staffing standards for di16 rect care registered nurses is a critical component of 

17 assuring that there is adequate hospital staffing at 

18 all levels to improve the delivery of quality care and 

19 protect patient safety. 

20 SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE 

21 STAFFING REQUIREMENT. 

22 (a) MINIMUM DIRECT CARE REGISTERED NURSE

23 STAFFING REQUIREMENTS.—The Public Health Service 

24 Act (42 U.S.C. 201 et seq.) is amended by adding at the 

25 end the following new title: 


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1 ‘‘TITLE XXXIV—MINIMUM DI2 RECT CARE REGISTERED 

3 NURSE STAFFING REQUIRE4 MENT 

5 ‘‘SEC. 3401. MINIMUM NURSE STAFFING REQUIREMENT. 

6 ‘‘(a) STAFFING PLAN.— 

7 ‘‘(1) IN GENERAL.—A hospital shall implement 

8 a staffing plan that— 

9 ‘‘(A) provides adequate, appropriate, and 

10 quality delivery of health care services and pro11 tects patient safety; and 

12 ‘‘(B) is consistent with the requirements of 

13 this title. 

14 ‘‘(2) EFFECTIVE DATES.— 

15 ‘‘(A) IMPLEMENTATION OF STAFFING

16 PLAN.—Subject to subparagraph (B), the re17 quirements under paragraph (1) shall take ef18 fect on a date to be determined by the Sec19 retary, but not later than 1 year after the date 

20 of the enactment of this title. 

21 ‘‘(B) APPLICATION OF MINIMUM DIRECT

22 CARE REGISTERED NURSE-TO-PATIENT RA23 TIOS.—The requirements under subsection (b) 

24 shall take effect as soon as practicable, as de25 termined by the Secretary, but not later than— 


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1 ‘‘(i) 2 years after the date of enact2 ment of this title; and 

3 ‘‘(ii) in the case of a hospital in a 

4 rural area (as defined in section 

5 1886(d)(2)(D) of the Social Security Act), 

6 4 years after the date of enactment of this 

7 title. 

8 ‘‘(b) MINIMUM DIRECT CARE REGISTERED NURSE9 TO-PATIENT RATIOS.— 

10 ‘‘(1) IN GENERAL.—Except as provided in para11 graph (4) and other provisions of this section, a hos12 pital’s staffing plan shall provide that, at all times 

13 during each shift within a unit of the hospital, and 

14 with a full complement of ancillary and support 

15 staff, a direct care registered nurse may be assigned 

16 to not more than the following number of patients 

17 in that unit: 

18 ‘‘(A) One patient in trauma emergency 

19 units. 

20 ‘‘(B) One patient in operating room units, 

21 provided that a minimum of 1 additional person 

22 serves as a scrub assistant in such unit. 

23 ‘‘(C) Two patients in critical care units, in24 cluding neonatal intensive care units, emer25 gency critical care and intensive care units, 


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1 labor and delivery units, coronary care units, 

2 acute respiratory care units, postanesthesia 

3 units, and burn units. 

4 ‘‘(D) Three patients in emergency room 

5 units, pediatrics units, stepdown units, telem6 etry units, antepartum units, and combined 

7 labor, deliver, and postpartum units. 

8 ‘‘(E) Four patients in medical-surgical 

9 units, intermediate care nursery units, acute 

10 care psychiatric units, and other specialty care 

11 units. 

12 ‘‘(F) Five patients in rehabilitation units 

13 and skilled nursing units. 

14 ‘‘(G) Six patients in postpartum (3 cou15 plets) units and well-baby nursery units. 

16 ‘‘(2) SIMILAR UNITS WITH DIFFERENT

17 NAMES.—The Secretary may apply minimum direct 

18 care registered nurse-to-patient ratios established in 

19 paragraph (1) for a hospital unit referred to in such 

20 paragraph to a type of hospital unit not referred to 

21 in such paragraph if such type of hospital unit pro22 vides a level of care to patients whose needs are 

23 similar to the needs of patients cared for in the hos24 pital unit referred to in such paragraph. 


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1 ‘‘(3) APPLICATION OF RATIOS TO HOSPITAL

2 NURSING PRACTICE STANDARDS.— 

3 ‘‘(A) IN GENERAL.—A patient assignment 

4 may be included in the calculation of the direct 

5 care registered nurse-to-patient ratios required 

6 in this subsection only if care is provided by a 

7 direct care registered nurse and the provision of 

8 care to the particular patient is within that di9 rect care registered nurse’s competence. 

10 ‘‘(B) DEMONSTRATION OF UNIT-SPECIFIC

11 COMPETENCE.—A hospital shall not assign a di12 rect care registered nurse to a hospital unit un13 less that hospital determines that the direct 

14 care registered nurse has demonstrated current 

15 competence in providing care in that unit, and 

16 has also received orientation to that hospital’s 

17 unit sufficient to provide competent care to pa18 tients in that unit. 

19 ‘‘(C) DUTIES OF THE ASSIGNED DIRECT

20 CARE REGISTERED NURSE.—Each patient shall 

21 be assigned to a direct care registered nurse 

22 who shall directly provide the assessment, plan23 ning, supervision, implementation, and evalua24 tion of the nursing care provided to the patient 

25 at least every shift and has the responsibility 


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1 for the provision of care to a particular patient 

2 within his or her scope of practice. 

3 ‘‘(D) NURSE ADMINISTRATORS AND SU4 PERVISORS.—A registered nurse who is a nurse 

5 administrator, nurse supervisor, nurse manager, 

6 charge nurse, case manager, or any other hos7 pital administrator or supervisor, shall not be 

8 included in the calculation of the direct care 

9 registered nurse-to-patient ratio unless that 

10 nurse has a current and active direct patient 

11 care assignment and provides direct patient 

12 care in compliance with the requirements of this 

13 section, including competency requirements. 

14 The exemption in this subsection shall apply 

15 only during the hours in which the individual 

16 registered nurse has the principal responsibility 

17 of providing direct patient care and has no ad18 ditional job duties as would a direct care reg19 istered nurse. 

20 ‘‘(E) OTHER PERSONNEL.—Other per21 sonnel may perform patient care tasks based on 

22 their training and demonstrated skill but may 

23 not perform or assist in direct care registered 

24 nurse functions unless authorized to do in acVerDate Sep 11 2014 00:43 May 11, 2017 Jkt 069200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S1063.IS S1063

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1 cordance with State scope of practice laws and 

2 regulations. 

3 ‘‘(F) TEMPORARY NURSING PERSONNEL.— 

4 A hospital shall not assign any nursing per5 sonnel from temporary nursing agencies patient 

6 care to any hospital unit without such personnel 

7 having demonstrated competence on the as8 signed unit and received orientation to that hos9 pital’s unit sufficient to provide competent care 

10 to patients in that unit. 

11 ‘‘(G) ANCILLARY AND ADDITIONAL STAFF12 ING.—The need for additional staffing of direct 

13 care registered nurses, licensed vocational or 

14 practical nurses, licensed psychiatric techni15 cians, certified nursing or patient care assist16 ants, or other licensed or unlicensed ancillary 

17 staff above the minimum registered nurse-to-pa18 tient ratios shall be based on the assessment of 

19 the individual patient’s nursing care require20 ment, the individual patient’s nursing care plan, 

21 and acuity level. 

22 ‘‘(4) RESTRICTIONS.— 

23 ‘‘(A) PROHIBITION AGAINST AVERAGING.— 

24 A hospital shall not average the number of pa25 tients and the total number of direct care regVerDate Sep 11 2014 00:43 May 11, 2017 Jkt 069200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S1063.IS S1063

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1 istered nurses assigned to patients in a hospital 

2 unit during any 1 shift or over any period of 

3 time for purposes of meeting the requirements 

4 under this subsection. 

5 ‘‘(B) PROHIBITION AGAINST IMPOSITION

6 OF MANDATORY OVERTIME REQUIREMENTS.—A 

7 hospital shall not impose mandatory overtime 

8 requirements to meet the hospital unit direct 

9 care registered nurse-to-patient ratios required 

10 under this subsection. 

11 ‘‘(C) RELIEF DURING ROUTINE AB12 SENCES.—A hospital shall ensure that only a 

13 direct care registered nurse who has dem14 onstrated current competence to the hospital in 

15 providing care on a particular unit and has also 

16 received orientation to that hospital’s unit suffi17 cient to provide competent care to patients in 

18 that unit may relieve another direct care reg19 istered nurse during breaks, meals, and other 

20 routine, expected absences from a hospital unit. 

21 ‘‘(D) APPLICATION OF DIRECT CARE REG22 ISTERED NURSE-TO-PATIENT RATIOS IN PA23 TIENT-ACUITY ADJUSTABLE UNITS.—Patients 

24 shall be cared for only on units or patient care 

25 areas where the direct care registered nurse-toVerDate Sep 11 2014 00:43 May 11, 2017 Jkt 069200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S1063.IS S1063

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1 patient ratios meet the level of intensity, type 

2 of care, and the individual requirements and 

3 needs of each patient. Notwithstanding para4 graph (2), hospitals that provide patient care in 

5 units or patient care areas that are acuity 

6 adaptable or acuity adjustable shall apply the 

7 direct care registered nurse-to-patient ratio re8 quired in this section for the highest patient 

9 acuity level or level of care in that unit or pa10 tient care area, and shall comply with all other 

11 requirements of this section. 

12 ‘‘(E) USE OF VIDEO MONITORS.—A hos13 pital shall not employ video monitors or any 

14 form of electronic visualization of a patient as 

15 a substitute for the direct observation required 

16 for patient assessment by the direct care reg17 istered nurse or required for patient protection. 

18 Video monitors or any form of electronic visual19 ization of a patient shall not be included in the 

20 calculation of the direct care registered nurse21 to-patient ratio required in this subsection and 

22 shall not replace the requirement of paragraph 

23 (3)(D) that each patient shall be assigned to a 

24 direct care registered nurse who shall directly 

25 provide the assessment, planning, supervision, 


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1 implementation, and evaluation of the nursing 

2 care provided to the patient at least every shift 

3 and have the responsibility for the provision of 

4 care to a particular patient within his or her 

5 scope of practice. 

6 ‘‘(F) USE OF OTHER TECHNOLOGY.—A 

7 hospital shall not employ technology that sub8 stitutes for the assigned registered nurse’s pro9 fessional judgment in assessment, planning, im10 plementation, and evaluation of care. 

11 ‘‘(5) ADJUSTMENT OF RATIOS.— 

12 ‘‘(A) IN GENERAL.—If necessary to protect 

13 patient safety, the Secretary may prescribe reg14 ulations that— 

15 ‘‘(i) increase minimum direct care reg16 istered nurse-to-patient ratios under this 

17 subsection to reduce the number of pa18 tients that may be assigned to each direct 

19 care nurse; or 

20 ‘‘(ii) add minimum direct care reg21 istered nurse-to-patient ratios for units not 

22 referred to in paragraphs (1) and (2). 

23 ‘‘(B) CONSULTATION.—Such regulations 

24 shall be prescribed after consultation with af25 fected hospitals and registered nurses. 


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1 ‘‘(6) ANCILLARY AND ADDITIONAL STAFFING.— 

2 ‘‘(A) IN GENERAL.—The Secretary may 

3 prescribe regulations requiring additional staff4 ing of direct care registered nurses, licensed vo5 cational or practice nurses, licensed psychiatric 

6 technicians, certified nursing or patient care as7 sistants, or other licensed or unlicensed ancil8 lary staff above the minimum registered nurse9 to-patient ratios that is based on the assess10 ment of the individual patient’s nursing care 

11 needs, the individual patient’s nursing care 

12 plan, and acuity level. 

13 ‘‘(B) CONSULTATION.—Such regulations 

14 shall be prescribed after consultation with af15 fected hospitals, registered nurses, and ancillary 

16 staff. 

17 ‘‘(7) RELATIONSHIP TO STATE-IMPOSED RA18 TIOS.—Nothing in this title shall preempt State 

19 standards that the Secretary determines to be as 

20 stringent as Federal requirements for a staffing plan 

21 established under this title. Minimum direct care 

22 registered nurse-to-patient ratios established under 

23 this subsection shall not preempt State requirements 

24 that the Secretary determines are as stringent as to 


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1 Federal requirements for direct care registered 

2 nurse-to-patient ratios established under this title. 

3 ‘‘(8) EXEMPTION IN EMERGENCIES.—The re4 quirements established under this subsection shall 

5 not apply during a state of emergency if a hospital 

6 is requested or expected to provide an exceptional 

7 level of emergency or other medical services. If a 

8 hospital seeks to apply the exemption under this 

9 paragraph in response to a complaint filed against 

10 the hospital for a violation of the provisions of this 

11 title, the hospital must demonstrate that prompt and 

12 diligent efforts were made to maintain required 

13 staffing levels. The Secretary shall issue guidance to 

14 hospitals that describes situations that constitute a 

15 state of emergency for purposes of the exemption 

16 under this paragraph and shall establish necessary 

17 penalties for violations of this paragraph consistent 

18 with section 3406. 

19 ‘‘(c) DEVELOPMENT AND REEVALUATION OF STAFF20 ING PLAN.— 

21 ‘‘(1) CONSIDERATIONS IN DEVELOPMENT OF

22 PLAN.—In developing the staffing plan, a hospital 

23 shall provide for direct care registered nurse-to-pa24 tient ratios above the minimum direct care reg25 istered nurse-to-patient ratios required under subVerDate Sep 11 2014 00:43 May 11, 2017 Jkt 069200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\S1063.IS S1063

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1 section (b) if appropriate based upon consideration 

2 of, at minimum, the following factors: 

3 ‘‘(A) The number of patients on a par4 ticular unit on a shift-by-shift basis. 

5 ‘‘(B) The acuity level and nursing care 

6 plan of patients on a particular unit on a shift7 by-shift basis. 

8 ‘‘(C) The anticipated admissions, dis9 charges, and transfers of patients during each 

10 shift that impacts direct patient care. 

11 ‘‘(D) Specialized experience required of di12 rect care registered nurses on a particular unit. 

13 ‘‘(E) Staffing levels and services provided 

14 by licensed vocational or practical nurses, li15 censed psychiatric technicians, certified nurse 

16 assistants, or other ancillary staff in meeting 

17 direct patient care needs not required by a di18 rect care registered nurse. 

19 ‘‘(F) The level of familiarity with hospital 

20 practices, policies, and procedures by temporary 

21 agency direct care registered nurses used dur22 ing a shift. 

23 ‘‘(G) Obstacles to efficiency in the delivery 

24 of patient care presented by physical layout. 


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1 ‘‘(2) DOCUMENTATION OF STAFFING.—A hos2 pital shall specify the system used to document ac3 tual staffing in each unit for each shift. 

4 ‘‘(3) ANNUAL REEVALUATION OF PLAN.— 

5 ‘‘(A) IN GENERAL.—A hospital shall annu6 ally evaluate its staffing plan in each unit in re7 lation to actual patient care requirements. 

8 ‘‘(B) UPDATE.—A hospital shall update its 

9 staffing plan to the extent appropriate based on 

10 such evaluation. 

11 ‘‘(4) TRANSPARENCY.— 

12 ‘‘(A) IN GENERAL.—Any staffing plan or 

13 method used to create and evaluate acuity-level 

14 and adopted by a hospital under this section 

15 shall be transparent in all respects, including 

16 disclosure of detailed documentation of the 

17 methodology used to determine nursing staff18 ing, identifying each factor, assumption, and 

19 value used in applying such methodology. 

20 ‘‘(B) PUBLIC AVAILABILITY.—The Sec21 retary shall establish procedures to provide that 

22 the documentation submitted under subsection 

23 (d) is available for public inspection in its en24 tirety. 


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1 ‘‘(5) REGISTERED NURSE PARTICIPATION.—A 

2 staffing plan of a hospital— 

3 ‘‘(A) shall be developed and subsequent re4 evaluations shall be conducted under this sub5 section on the basis of input from direct care 

6 registered nurses at the hospital from each unit 

7 or patient care area; and 

8 ‘‘(B) where such nurses are represented 

9 through collective bargaining, shall require bar10 gaining with the applicable recognized or cer11 tified collective bargaining representative of 

12 such nurses. 

13 Nothing in this title shall be construed to permit 

14 conduct prohibited under the National Labor Rela15 tions Act (29 U.S.C. 151 et seq.) or chapter 71 of 

16 title 5, United States Code. 

17 ‘‘(6) STAFFING COMMITTEES.—If a hospital 

18 maintains a staffing committee, then the committee 

19 shall include at least one registered nurse from each 

20 hospital unit and shall be composed of at least 50 

21 percent direct care registered nurses. The staffing 

22 committee shall include meaningful representation of 

23 other direct care nonmanagement staff. Direct care 

24 registered nurses who serve on the committee shall 

25 be selected by other direct care registered nurses 


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1 from their unit. Other direct care nonmanagement 

2 staff shall be selected by other direct care non3 management staff. Participation on staffing commit4 tees shall be considered a part of the employee’s reg5 ularly scheduled workweek. 

6 ‘‘(d) SUBMISSION OF PLAN TO SECRETARY.—A hos7 pital shall submit to the Secretary its staffing plan and 

8 any annual updates under subsection (c)(3)(B). A feder9 ally operated hospital may submit its staffing plan 

10 through the department or agency operating the hospital. 

11 ‘‘SEC. 3402. POSTING, RECORDS, AND AUDITS. 

12 ‘‘(a) POSTING REQUIREMENTS.—In each unit, a hos13 pital shall post a uniform notice in a form specified by 

14 the Secretary in regulation that— 

15 ‘‘(1) explains requirements imposed under sec16 tion 3401; 

17 ‘‘(2) includes actual direct care registered 

18 nurse-to-patient ratios during each shift; 

19 ‘‘(3) includes the actual number and titles of di20 rect care registered nurses assigned during each 

21 shift; and 

22 ‘‘(4) is visible, conspicuous, and accessible to 

23 staff, patients, and the public. 

24 ‘‘(b) RECORDS.— 


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1 ‘‘(1) MAINTENANCE OF RECORDS.—Each hos2 pital shall maintain accurate records of actual direct 

3 care registered nurse-to-patient ratios in each unit 

4 for each shift for no less than 3 years. Such records 

5 shall include— 

6 ‘‘(A) the number of patients in each unit; 

7 ‘‘(B) the identity and duty hours of— 

8 ‘‘(i) each direct care registered nurse 

9 assigned to each patient in each unit in 

10 each shift; and 

11 ‘‘(ii) ancillary staff who are under the 

12 coordination of the direct care registered 

13 nurse; 

14 ‘‘(C) certification that each nurse received 

15 rest and meal breaks and the identity and duty 

16 hours of each direct care registered nurse who 

17 provided such relief; and 

18 ‘‘(D) a copy of each notice posted under 

19 subsection (a). 

20 ‘‘(2) AVAILABILITY OF RECORDS.—Each hos21 pital shall make its records maintained under para22 graph (1) available to— 

23 ‘‘(A) the Secretary; 

24 ‘‘(B) registered nurses and their collective 

25 bargaining representatives (if any); and 


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1 ‘‘(C) the public under regulations estab2 lished by the Secretary, or in the case of a fed3 erally operated hospital, under section 552 of 

4 title 5, United States Code (commonly known 

5 as the Freedom of Information Act). 

6 ‘‘(c) AUDITS.—The Secretary shall conduct periodic 

7 audits to ensure— 

8 ‘‘(1) implementation of the staffing plan in ac9 cordance with this title; and 

10 ‘‘(2) accuracy in records maintained under this 

11 section. 

12 ‘‘SEC. 3403. MINIMUM DIRECT CARE LICENSED PRACTICAL 

13 NURSE STAFFING REQUIREMENTS. 

14 ‘‘(a) ESTABLISHMENT.—A hospital’s staffing plan 

15 shall comply with minimum direct care licensed practical 

16 nurse staffing requirements that the Secretary establishes 

17 for units in hospitals. Such staffing requirements shall be 

18 established not later than 18 months after the date of the 

19 enactment of this title, and shall be based on the study 

20 conducted under subsection (b). 

21 ‘‘(b) STUDY.—Not later than 1 year after the date 

22 of the enactment of this title, the Secretary, acting 

23 through the Director of the Agency for Healthcare Re24 search and Quality, shall complete a study of licensed 

25 practical nurse staffing and its effects on patient care in 


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1 hospitals. The Director may contract with a qualified enti2 ty or organization to carry out such study under this para3 graph. The Director shall consult with licensed practical 

4 nurses and organizations representing licensed practical 

5 nurses regarding the design and conduct of the study. 

6 ‘‘(c) APPLICATION OF REGISTERED NURSE PROVI7 SIONS TO LICENSED PRACTICAL NURSE STAFFING RE8 QUIREMENTS.—Paragraphs (2), (4)(A), (4)(B), (4)(C), 

9 and (6) of section 3401(b), paragraphs (1), (2), (3), and 

10 (4) of section 3401(c), and section 3402 shall apply to 

11 the establishment and application of direct care licensed 

12 practical nurse staffing requirements under this section 

13 pursuant to the additional staffing requirements under 

14 subsection (b)(3)(G) of section 3401 and in the same man15 ner that they apply to the establishment and application 

16 of direct care registered nurse-to-patient ratios under sec17 tions 3401 and 3402. 

18 ‘‘(d) EFFECTIVE DATE.—The requirements of this 

19 section shall take effect as soon as practicable, as deter20 mined by the Secretary, but not later than— 

21 ‘‘(1) 2 years after the date of the enactment of 

22 this title; and 

23 ‘‘(2) in the case of a hospital in a rural area 

24 (as defined in section 1886(d)(2)(D) of the Social 


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1 Security Act), 4 years after the date of the enact2 ment of this title. 

3 ‘‘(e) STUDY.—Not later than 1 year after the date 

4 of the enactment of this title, the Secretary, acting 

5 through the Director of the Agency for Healthcare Re6 search and Quality shall complete a study of registered 

7 and practical nurse staffing requirements in clinics and 

8 other outpatient settings, and its effects on patient care 

9 in outpatient settings. The Director may contract with a 

10 qualified entity or organization to carry out such study 

11 under this subsection. The Director shall consult with reg12 istered nurses and licensed practice nurses working in out13 patient settings, including professional nursing associa14 tions and labor organizations representing both registered 

15 and practice nurses working in outpatient settings regard16 ing the design and conduct of the study. 

17 ‘‘SEC. 3404. ADJUSTMENT IN REIMBURSEMENT. 

18 ‘‘(a) MEDICARE REIMBURSEMENT.—The Secretary 

19 shall adjust payments made to hospitals (other than feder20 ally operated hospitals) under title XVIII of the Social Se21 curity Act in an amount equal to the net amount of addi22 tional costs incurred in providing services to Medicare 

23 beneficiaries that are attributable to compliance with re24 quirements imposed under sections 3401 through 3403. 

25 The amount of such payment adjustments shall take into 


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1 account recommendations contained in the report sub2 mitted by the Medicare Payment Advisory Commission 

3 under subsection (c). 

4 ‘‘(b) AUTHORIZATION OF APPROPRIATION FOR FED5 ERALLY OPERATED HOSPITALS.—There are authorized to 

6 be appropriated such additional sums as are required for 

7 federally operated hospitals to comply with the additional 

8 requirements established under sections 3401 through 

9 3403. 

10 ‘‘(c) MEDPAC REPORT.—Not later than 2 years after 

11 the date of the enactment of this title, the Medicare Pay12 ment Advisory Commission (established under section 

13 1805 of the Social Security Act) shall submit to Congress 

14 and the Secretary a report estimating total costs and sav15 ings attributable to compliance with requirements imposed 

16 under sections 3401 through 3403. Such report shall in17 clude recommendations on the need, if any, to adjust reim18 bursement for Medicare payments under subsection (a). 

19 ‘‘SEC. 3405. WHISTLEBLOWER AND PATIENT PROTECTIONS. 

20 ‘‘(a) PROFESSIONAL OBLIGATION AND RIGHTS.—All 

21 nurses have a duty and right to act based on their profes22 sional judgment in accordance with State nursing laws 

23 and regulations of the State in which the direct nursing 

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1 sive interests of the patients and to act as the patient’s 

2 advocate. 

3 ‘‘(b) ACCEPTANCE OF PATIENT CARE ASSIGN4 MENTS.—The nurse is responsible for providing com5 petent, safe, therapeutic, and effective nursing care to as6 signed patients. Before accepting a patient assignment, a 

7 nurse shall— 

8 ‘‘(1) have the necessary professional knowledge, 

9 judgment, skills, and ability to provide the required 

10 care; 

11 ‘‘(2) determine using professional judgment in 

12 accordance with State nursing laws and regulations 

13 of the State in which the direct nursing care is being 

14 performed whether the nurse is competent to per15 form the nursing care required; and 

16 ‘‘(3) determine whether acceptance of a patient 

17 assignment would expose the patient or nurse to risk 

18 of harm. 

19 ‘‘(c) OBJECTION TO OR REFUSAL OF ASSIGNMENT.— 

20 A nurse may object to, or refuse to participate in, any 

21 activity, policy, practice, assignment, or task if in good 

22 faith— 

23 ‘‘(1) the nurse reasonably believes it to be in 

24 violation of section 3401 or 3403; or 


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1 ‘‘(2) the nurse is not prepared by education, 

2 training, or experience to fulfill the assignment with3 out compromising the safety of any patient or jeop4 ardizing the license of the nurse. 

5 ‘‘(d) RETALIATION FOR OBJECTION TO OR REFUSAL

6 OF ASSIGNMENT BARRED.— 

7 ‘‘(1) NO DISCHARGE, DISCRIMINATION, OR RE8 TALIATION.—No hospital shall discharge, retaliate, 

9 discriminate, or otherwise take adverse action in any 

10 manner with respect to any aspect of a nurse’s em11 ployment (as defined in section 3407), including dis12 charge, promotion, compensation, or terms, condi13 tions, or privileges of employment, based on the 

14 nurse’s refusal of a work assignment under sub15 section (c). 

16 ‘‘(2) NO FILING OF COMPLAINT.—No hospital 

17 shall file a complaint or a report against a nurse 

18 with a State professional disciplinary agency because 

19 of the nurse’s refusal of a work assignment under 

20 subsection (c). 

21 ‘‘(e) CAUSE OF ACTION.—Any nurse, collective bar22 gaining representative, or legal representative of any nurse 

23 who has been discharged, discriminated against, or retali24 ated against in violation of subsection (d)(1) or against 

25 whom a complaint or report has been filed in violation of 


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1 subsection (d)(2) may (without regard to whether a com2 plaint has been filed under subsection (f) of this section 

3 or subsection (b) of section 3406) bring a cause of action 

4 in a United States district court. A nurse who prevails 

5 on the cause of action shall be entitled to one or more 

6 of the following: 

7 ‘‘(1) Reinstatement. 

8 ‘‘(2) Reimbursement of lost wages, compensa9 tion, and benefits. 

10 ‘‘(3) Attorneys’ fees. 

11 ‘‘(4) Court costs. 

12 ‘‘(5) Other damages. 

13 ‘‘(f) COMPLAINT TO SECRETARY.—A nurse, patient, 

14 collective bargaining representative, or other individual 

15 may file a complaint with the Secretary against a hospital 

16 that violates the provisions of this title. For any complaint 

17 filed, the Secretary shall— 

18 ‘‘(1) receive and investigate the complaint; 

19 ‘‘(2) determine whether a violation of this title 

20 as alleged in the complaint has occurred; and 

21 ‘‘(3) if such a violation has occurred, issue an 

22 order that the complaining nurse or individual shall 

23 not suffer any discharge, retaliation, discrimination, 

24 or other adverse action prohibited by subsection (d) 

25 or subsection (h). 


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1 ‘‘(g) TOLL-FREE TELEPHONE NUMBER.— 

2 ‘‘(1) IN GENERAL.—The Secretary shall provide 

3 for the establishment of a toll-free telephone hotline 

4 to provide information regarding the requirements 

5 under section 3401 through 3403 and to receive re6 ports of violations of such section. 

7 ‘‘(2) NOTICE TO PATIENTS.—A hospital shall 

8 provide each patient admitted to the hospital for in9 patient care with the hotline described in paragraph 

10 (1), and shall give notice to each patient that such 

11 hotline may be used to report inadequate staffing or 

12 care. 

13 ‘‘(h) PROTECTION FOR REPORTING.— 

14 ‘‘(1) PROHIBITION ON RETALIATION OR DIS15 CRIMINATION.—A hospital shall not discriminate or 

16 retaliate in any manner against any patient, em17 ployee, or contract employee of the hospital, or any 

18 other individual, on the basis that such individual, in 

19 good faith, individually or in conjunction with an20 other person or persons, has presented a grievance 

21 or complaint, or has initiated or cooperated in any 

22 investigation or proceeding of any governmental en23 tity, regulatory agency, or private accreditation 

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1 tion relating to the care, services, or conditions of 

2 the hospital or of any affiliated or related facilities. 

3 ‘‘(2) GOOD FAITH DEFINED.—For purposes of 

4 this subsection, an individual shall be deemed to be 

5 acting in good faith if the individual reasonably be6 lieves— 

7 ‘‘(A) the information reported or disclosed 

8 is true; and 

9 ‘‘(B) a violation of this title has occurred 

10 or may occur. 

11 ‘‘(i) PROHIBITION ON INTERFERENCE WITH

12 RIGHTS.— 

13 ‘‘(1) EXERCISE OF RIGHTS.—It shall be unlaw14 ful for any hospital to— 

15 ‘‘(A) interfere with, restrain, or deny the 

16 exercise, or attempt to exercise, by any person 

17 of any right provided or protected under this 

18 title; or 

19 ‘‘(B) coerce or intimidate any person re20 garding the exercise or attempt to exercise such 

21 right. 

22 ‘‘(2) OPPOSITION TO UNLAWFUL POLICIES OR

23 PRACTICES.—It shall be unlawful for any hospital to 

24 discriminate or retaliate against any person for op25 posing any hospital policy, practice, or actions which 


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1 are alleged to violate, breach, or fail to comply with 

2 any provision of this title. 

3 ‘‘(3) PROHIBITION ON INTERFERENCE WITH

4 PROTECTED COMMUNICATIONS.—A hospital (or an 

5 individual representing a hospital) shall not make, 

6 adopt, or enforce any rule, regulation, policy, or 

7 practice which in any manner directly or indirectly 

8 prohibits, impedes, or discourages a direct care 

9 nurse from, or intimidates, coerces, or induces a di10 rect care nurse regarding, engaging in free speech 

11 activities or disclosing information as provided under 

12 this title. 

13 ‘‘(4) PROHIBITION ON INTERFERENCE WITH

14 COLLECTIVE ACTION.—A hospital (or an individual 

15 representing a hospital) shall not in any way inter16 fere with the rights of nurses to organize, bargain 

17 collectively, and engage in concerted activity under 

18 section 7 of the National Labor Relations Act (29 

19 U.S.C. 157). 

20 ‘‘(j) NOTICE.—A hospital shall post in an appropriate 

21 location in each unit a conspicuous notice in a form speci22 fied by the Secretary that— 

23 ‘‘(1) explains the rights of nurses, patients, and 

24 other individuals under this section; 


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1 ‘‘(2) includes a statement that a nurse, patient, 

2 or other individual may file a complaint with the 

3 Secretary against a hospital that violates the provi4 sions of this title; and 

5 ‘‘(3) provides instructions on how to file such a 

6 complaint. 

7 ‘‘(k) EFFECTIVE DATE.— 

8 ‘‘(1) REFUSAL; RETALIATION; CAUSE OF AC9 TION.— 

10 ‘‘(A) IN GENERAL.—Subsections (c) 

11 through (e) shall apply to objections and refus12 als occurring on or after the effective date of 

13 the provision of this title to which the objection 

14 or refusal relates. 

15 ‘‘(B) EXCEPTION.—Subsection (c)(2) shall 

16 not apply to objections or refusals in any hos17 pital before the requirements of section 3401(a) 

18 or 3403(a), as applicable, apply to that hos19 pital. 

20 ‘‘(2) PROTECTIONS FOR REPORTING.—Sub21 section (h)(1) shall apply to actions occurring on or 

22 after the effective date of the provision to which the 

23 violation relates, except that such subsection shall 

24 apply to initiation, cooperation, or participation in 


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1 an investigation or proceeding on or after the date 

2 of enactment of this title. 

3 ‘‘(3) NOTICE.—Subsection (j) shall take effect 

4 18 months after the date of enactment of this title. 

5 ‘‘SEC. 3406. ENFORCEMENT. 

6 ‘‘(a) IN GENERAL.—The Secretary shall enforce the 

7 requirements and prohibitions of this title in accordance 

8 with this section. 

9 ‘‘(b) PROCEDURES FOR RECEIVING AND INVES10 TIGATING COMPLAINTS.—The Secretary shall establish 

11 procedures under which— 

12 ‘‘(1) any person may file a complaint alleging 

13 that a hospital has violated a requirement or a pro14 hibition of this title; and 

15 ‘‘(2) such complaints shall be investigated by 

16 the Secretary. 

17 ‘‘(c) REMEDIES.—If the Secretary determines that a 

18 hospital has violated a requirement of this title, the Sec19 retary— 

20 ‘‘(1) shall require the facility to establish a cor21 rective action plan to prevent the recurrence of such 

22 violation; and 

23 ‘‘(2) may impose civil money penalties, as de24 scribed in subsection (d). 

25 ‘‘(d) CIVIL PENALTIES.— 


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1 ‘‘(1) IN GENERAL.—In addition to any other 

2 penalties prescribed by law, the Secretary may im3 pose civil penalties as follows: 

4 ‘‘(A) HOSPITAL LIABILITY.—The Secretary 

5 may impose on a hospital found to be in viola6 tion of this title a civil money penalty of— 

7 ‘‘(i) not more than $25,000 for the 

8 first knowing violation of this title by such 

9 hospital; and 

10 ‘‘(ii) not more than $50,000 for any 

11 subsequent knowing violation of this title 

12 by such hospital. 

13 ‘‘(B) INDIVIDUAL LIABILITY.—The Sec14 retary may impose on an individual who— 

15 ‘‘(i) is employed by a hospital found 

16 by the Secretary to have violated this title; 

17 and 

18 ‘‘(ii) knowingly violates this title, 

19 a civil money penalty of not more than $20,000 

20 for each such violation by the individual. 

21 ‘‘(2) PROCEDURES.—The provisions of section 

22 1128A of the Social Security Act (other than sub23 sections (a) and (b)) shall apply with respect to a 

24 civil money penalty or proceeding under this sub25 section in the same manner as such provisions apply 


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1 with respect to a civil money penalty or proceeding 

2 under such section 1128A. 

3 ‘‘(e) PUBLIC NOTICE OF VIOLATIONS.— 

4 ‘‘(1) INTERNET WEBSITE.—The Secretary shall 

5 publish on the internet website of the Department of 

6 Health and Human Services the names of hospitals 

7 on which a civil money penalty has been imposed 

8 under this section, the violation for which such pen9 alty was imposed, and such additional information 

10 as the Secretary determines appropriate. 

11 ‘‘(2) CHANGE OF OWNERSHIP.—With respect to 

12 a hospital that had a change of ownership, as deter13 mined by the Secretary, penalties imposed on the 

14 hospital while under previous ownership shall no 

15 longer be published by the Secretary pursuant to 

16 paragraph (1) after the 1-year period beginning on 

17 the date of change of ownership. 

18 ‘‘(f) USE OF FUNDS.—Funds collected by the Sec19 retary pursuant to this section are authorized to be appro20 priated to carry out this title. 

21 ‘‘SEC. 3407. DEFINITIONS. 

22 ‘‘For purposes of this title: 

23 ‘‘(1) ACUITY LEVEL.—The term ‘acuity level’ 

24 means the determination, using a hospital acuity 

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1 tablished in coordination with direct care registered 

2 nurses and made transparent pursuant to section 

3 3401(c)(4), of nursing care requirements, based on 

4 the assigned direct care registered nurse’s profes5 sional judgment of— 

6 ‘‘(A) the severity and complexity of an in7 dividual patient’s illness or injury; 

8 ‘‘(B) the need for specialized equipment; 

9 and 

10 ‘‘(C) the intensity of nursing interventions 

11 required. 

12 ‘‘(2) COMPETENCE.—The term ‘competence’ or 

13 ‘competent’ means the satisfactory application of the 

14 duties and responsibilities of a registered nurse in 

15 providing nursing care to specific patient popu16 lations and for acuity levels for each patient care 

17 unit or area pursuant to the State nursing laws and 

18 regulations of the State in which the direct nursing 

19 care is being performed. 

20 ‘‘(3) DIRECT CARE LICENSED PRACTICAL

21 NURSE.—The term ‘direct care licensed practical 

22 nurse’ means an individual who has been granted a 

23 license by at least one State to practice as a licensed 

24 practical nurse or a licensed vocational nurse and 

25 who provides bedside care for one or more patients. 


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1 ‘‘(4) DIRECT CARE REGISTERED NURSE.—The 

2 term ‘direct care registered nurse’ means an indi3 vidual who has been granted a license by at least 

4 one State to practice as a registered nurse and who 

5 provides bedside care for one or more patients. 

6 ‘‘(5) EMPLOYMENT.—The term ‘employment’ 

7 includes the provision of services under a contract or 

8 other arrangement. 

9 ‘‘(6) HOSPITAL.—The term ‘hospital’ has the 

10 meaning given that term in section 1861(e) of the 

11 Social Security Act, and includes a hospital that is 

12 operated by the Department of Veterans Affairs, the 

13 Department of Defense, the Indian Health Services 

14 Program, or any other department or agency of the 

15 United States. 

16 ‘‘(7) NURSE.—The term ‘nurse’ means any di17 rect care registered nurse or direct care licensed 

18 practice nurse (as the case may be), regardless of 

19 whether or not the nurse is an employee. 

20 ‘‘(8) NURSING CARE PLAN.—The term ‘nursing 

21 care plan’ means a plan developed by the assigned 

22 direct care registered nurse (in accordance with 

23 nursing law in the State in which the nursing care 

24 is performed) that indicates the nursing care to be 

25 given to individual patients that— 


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1 ‘‘(A) considers the acuity level of the pa2 tient; 

3 ‘‘(B) is developed in coordination with the 

4 patient, the patient’s family, or other represent5 atives when appropriate, and staff of other dis6 ciplines involved in the care of the patient; 

7 ‘‘(C) reflects all elements of the nursing 

8 process; and 

9 ‘‘(D) recommends the number and skill 

10 mix of additional licensed and unlicensed direct 

11 care staff needed to fully implement the nursing 

12 care plan. 

13 ‘‘(9) PROFESSIONAL JUDGMENT.—The term 

14 ‘professional judgment’ means, in accordance with 

15 State nursing laws and regulations of the State in 

16 which the direct nursing care is being performed, the 

17 direct care registered nurse’s application of knowl18 edge, expertise, and experience in conducting a com19 prehensive nursing assessment of each patient and 

20 in making independent decisions about patient care 

21 including the need for additional staff. 

22 ‘‘(10) STAFFING PLAN.—The term ‘staffing 

23 plan’ means a staffing plan required under section 

24 3401. 


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1 ‘‘(11) STATE OF EMERGENCY.—The term ‘state 

2 of emergency’— 

3 ‘‘(A) means a state of emergency that is 

4 an unpredictable or unavoidable occurrence at 

5 an unscheduled or unpredictable interval, relat6 ing to health care delivery and requiring imme7 diate medical interventions and care; and 

8 ‘‘(B) does not include a state of emergency 

9 that results from a labor dispute in the health 

10 care industry or consistent understaffing. 

11 ‘‘SEC. 3408. RULE OF CONSTRUCTION. 

12 ‘‘Nothing in this title shall be construed to authorize 

13 disclosure of private and confidential patient information, 

14 if such disclosure is not authorized or required by other 

15 applicable law.’’. 

16 (b) RECOMMENDATIONS TO CONGRESS.—Not later 

17 than 1 year after the date of enactment of this Act, the 

18 Secretary of Health and Human Services shall submit to 

19 Congress a report containing recommendations for ensur20 ing that sufficient numbers of nurses are available to meet 

21 the requirements imposed by title XXXIV of the Public 

22 Health Service Act, as added by subsection (a). 

23 (c) REPORT BY HRSA.— 

24 (1) IN GENERAL.—Not later than 2 years after 

25 the date of enactment of this Act, the Administrator 


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1 of the Health Resources and Services Administra2 tion, in consultation with the National Health Care 

3 Workforce Commission, shall submit to Congress a 

4 report regarding the relationship between nurse 

5 staffing levels and nurse retention in hospitals. 

6 (2) UPDATED REPORT.—Not later than 5 years 

7 after the date of enactment of this Act, the Adminis8 trator of the Health Resources and Services Admin9 istration, in consultation with the National Health 

10 Care Workforce Commission, shall submit to Con11 gress an update of the report submitted under para12 graph (1). 

13 SEC. 3. ENFORCEMENT OF REQUIREMENTS THROUGH FED14 ERAL PROGRAMS. 

15 (a) MEDICARE PROGRAM.—Section 1866(a)(1) of the 

16 Social Security Act (42 U.S.C. 1395cc(a)(1)) is amend17 ed— 

18 (1) in subparagraph (X), by striking ‘‘, and’’ 

19 and inserting a comma; 

20 (2) in subparagraph (Y), by striking the period 

21 at the end and inserting ‘‘, and’’; and 

22 (3) by inserting after the subparagraph (Y) the 

23 following new subparagraph: 


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1 ‘‘(Z) in the case of a hospital, to comply with 

2 the provisions of title XXXIV of the Public Health 

3 Service Act.’’. 

4 (b) MEDICAID PROGRAM.—Section 1902(a) of the 

5 Social Security Act (42 U.S.C. 1396a(a)) is amended— 

6 (1) by striking ‘‘and’’ at the end of paragraph 

7 (82); 

8 (2) by striking the period at the end of para9 graph (83) and inserting ‘‘; and’’; and 

10 (3) by inserting after paragraph (83) the fol11 lowing new paragraph: 

12 ‘‘(84) provide that any hospital that receives a 

13 payment under such plan comply with the provisions 

14 of title XXXIV of the Public Health Service Act (re15 lating to minimum direct care registered nurse staff16 ing requirements).’’. 

17 (c) HEALTH BENEFITS PROGRAM OF THE DEPART18 MENT OF VETERANS AFFAIRS.—Section 8110(a) of title 

19 38, United States Code, is amended by adding at the end 

20 the following new paragraphs: 

21 ‘‘(7) In the case of a Department medical facil22 ity that is a hospital, the hospital shall comply with 

23 the provisions of title XXXIV of the Public Health 

24 Service Act. 


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1 ‘‘(8) Nothing either in chapter 74 of this title 

2 or in section 7106 of title 5 shall preclude enforce3 ment of the provisions of title XXXIV of the Public 

4 Health Service Act with respect to a Department 

5 hospital through grievance procedures negotiated in 

6 accordance with chapter 71 of title 5.’’. 

7 (d) HEALTH BENEFITS PROGRAM OF THE DEPART8 MENT OF DEFENSE.— 

9 (1) IN GENERAL.—Chapter 55 of title 10, 

10 United States Code, is amended by adding at the 

11 end the following new section: 

12 ‘‘§ 1110c. Staffing requirements 

13 ‘‘In the case of a facility of the uniformed services 

14 that is a hospital, the hospital shall comply with the provi15 sions of title XXXIV of the Public Health Service Act.’’. 

16 (2) CLERICAL AMENDMENT.—The table of sec17 tions at the beginning of such chapter is amended 

18 by inserting after the item relating to section 1110b 

19 the following new item: 

‘‘1110c. Staffing requirements.’’. 

20 (e) INDIAN HEALTH SERVICES PROGRAM.—Title 

21 VIII of the Indian Health Care Improvement Act (25 

22 U.S.C. 1671 et seq.) is amended by adding at the end 

23 the following new section: 


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1 ‘‘SEC. 833. STAFFING REQUIREMENTS. 

2 ‘‘All hospitals of the Service shall comply with the 

3 provisions of title XXXIV of the Public Health Service Act 

4 (relating to minimum direct care registered nurse staffing 

5 requirements).’’. 

6 (f) FEDERAL LABOR-MANAGEMENT RELATIONS.— 

7 (1) IN GENERAL.—Section 7106 of title 5, 

8 United States Code, is amended by adding at the 

9 end the following: 

10 ‘‘(c) Nothing in this section shall preclude enforce11 ment of the provisions of title XXXIV of the Public Health 

12 Service Act through grievance procedures negotiated in ac13 cordance with section 7121.’’. 

14 (2) CONFORMING AMENDMENT.—Section 

15 7106(a) of title 5, United States Code, is amended 

16 by striking ‘‘Subject to subsection (b) of this title,’’ 

17 and inserting ‘‘Subject to subsections (b) and (c),’’. 

18 SEC. 4. NURSE WORKFORCE INITIATIVE. 

19 (a) SCHOLARSHIP AND STIPEND PROGRAM.—Section 

20 846(d) of the Public Health Service Act (42 U.S.C. 

21 297n(d)) is amended— 

22 (1) in the section heading, by inserting ‘‘AND

23 STIPEND’’ after ‘‘SCHOLARSHIP’’; and 

24 (2) in paragraph (1), by inserting ‘‘or stipends’’ 

25 after ‘‘scholarships’’. 


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1 (b) NURSE RETENTION GRANTS.—Section 831A(b) 

2 of the Public Health Service Act (42 U.S.C. 296p–1(b)) 

3 is amended— 

4 (1) by striking ‘‘GRANTS FOR CAREER LADDER

5 PROGRAM.—’’ and inserting ‘‘GRANTS FOR NURSE

6 RETENTION.—’’; 

7 (2) in paragraph (2), by striking ‘‘; or’’ and in8 serting a semicolon; 

9 (3) in paragraph (3), by striking the period and 

10 inserting a semicolon; and 

11 (4) by adding at the end the following: 

12 ‘‘(4) to provide additional support to nurses en13 tering the workforce by implementing nursing pre14 ceptorship projects that establish a period of prac15 tical and clinical experiences and training for nurs16 ing students, newly hired nurses, and recent grad17 uates of a direct care degree program for registered 

18 nurses; or 

19 ‘‘(5) to implement mentorship projects that as20 sist new or transitional direct care registered nurses 

21 in adapting to the hospital setting.’’. 

Æ 


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