II 

113TH CONGRESS 

1ST SESSION S. 739 

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 

APRIL 16, 2013 

Mrs. BOXER 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. 

4 This Act may be cited as the ‘‘National Nursing 

5 Shortage Reform and Patient Advocacy Act’’. 

6 SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE 

7 STAFFING REQUIREMENTS. 

8 (a) MINIMUM DIRECT CARE REGISTERED NURSE

9 STAFFING REQUIREMENTS.—The Public Health Service 

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

2 end the following new title: 

3 ‘‘TITLE XXXIV—MINIMUM DI4 RECT CARE REGISTERED 

5 NURSE STAFFING REQUIRE6 MENTS 

7 ‘‘SEC. 3401. MINIMUM NURSE STAFFING REQUIREMENTS. 

8 ‘‘(a) STAFFING PLAN.— 

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

10 a staffing plan that— 

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

12 quality delivery of health care services and pro13 tects patient safety; and 

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

15 this title. 

16 ‘‘(2) EFFECTIVE DATES.— 

17 ‘‘(A) IMPLEMENTATION OF STAFFING

18 PLAN.—Subject to subparagraph (B), the re19 quirements under paragraph (1) shall take ef20 fect not later than 1 year after the date of en21 actment of this title. 

22 ‘‘(B) APPLICATION OF MINIMUM DIRECT

23 CARE REGISTERED NURSE-TO-PATIENT RA24 TIOS.—The requirements under subsection (b) 

25 shall take effect as soon as practicable, as demstockstill on DSK4VPTVN1PROD with BILLS

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1 termined by the Secretary, but not later than 2 

2 years after the date of enactment of this title, 

3 or in the case of a hospital in a rural area (as 

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

5 Security Act), not later than 4 years after the 

6 date of enactment of this title. 

7 ‘‘(b) MINIMUM DIRECT CARE REGISTERED NURSE8 TO-PATIENT RATIOS.— 

9 ‘‘(1) IN GENERAL.—Except as otherwise pro10 vided in this section, a hospital’s staffing plan shall 

11 provide that, at all times during each shift within a 

12 unit of the hospital, a direct care registered nurse 

13 shall be assigned to not more than the following 

14 number of patients in that unit, subject to para15 graph (4): 

16 ‘‘(A) One patient in trauma emergency 

17 units. 

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

19 provided that a minimum of 1 additional person 

20 serves as a scrub assistant in such unit. 

21 ‘‘(C) Two patients in critical care units, in22 cluding neonatal intensive care units, emer23 gency critical care and intensive care units, 

24 labor and delivery units, coronary care units, 

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1 acute respiratory care units, postanesthesia 

2 units, and burn units. 

3 ‘‘(D) Three patients in emergency room 

4 units, stepdown units, pediatrics units, telem5 etry units, antepartum units, and combined 

6 labor, delivery, and postpartum units. 

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

8 units, intermediate care nursery units, psy9 chiatric units, and other specialty care units. 

10 ‘‘(F) Five patients in rehabilitation units, 

11 and skilled nursing units. 

12 ‘‘(G) Six patients in well-baby nursery 

13 units and postpartum (3 couplets) units. 

14 ‘‘(2) UNITS WITH DIFFERENT NAMES.—The 

15 Secretary may apply minimum direct care registered 

16 nurse-to-patient ratios established in paragraph (1) 

17 to a type of hospital unit not referred to in such 

18 paragraph if such other unit provides a level of care 

19 to patients whose needs are similar to the needs of 

20 patients cared for in any unit referred to in such 

21 paragraph. 

22 ‘‘(3) RESTRICTIONS.— 

23 ‘‘(A) PROHIBITION AGAINST AVERAGING.— 

24 A hospital shall not average the number of pa25 tients and the total number of direct care regmstockstill on DSK4VPTVN1PROD with BILLS

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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 may relieve another 

14 direct care registered nurse during breaks, 

15 meals, and other routine, expected absences 

16 from a hospital unit. 

17 ‘‘(4) ADJUSTMENT OF RATIOS.— 

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

19 patient safety, the Secretary may prescribe reg20 ulations that— 

21 ‘‘(i) increase minimum direct care reg22 istered nurse-to-patient ratios under this 

23 subsection to further limit the number of 

24 patients that may be assigned to each di25 rect care nurse; or 

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1 ‘‘(ii) add minimum direct care reg2 istered nurse-to-patient ratios for units not 

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

4 ‘‘(B) CONSULTATION.—Such regulations 

5 shall be prescribed after consultation with af6 fected hospitals and registered nurses. 

7 ‘‘(5) NO PREEMPTION OF CERTAIN STATE-IM8 POSED RATIOS.—Nothing in this title shall preempt 

9 State standards that the Secretary determines to be 

10 at least equivalent to Federal requirements for a 

11 staffing plan established under this title. Minimum 

12 direct care registered nurse-to-patient ratios estab13 lished under this subsection shall not preempt State 

14 requirements that the Secretary determines are at 

15 least equivalent to Federal requirements for a staff16 ing plan established under this title. 

17 ‘‘(6) EXEMPTION IN EMERGENCIES.— 

18 ‘‘(A) IN GENERAL.—The requirements es19 tablished under this subsection shall not apply 

20 during a state of emergency if a hospital is re21 quested or expected to provide an exceptional 

22 level of emergency or other medical services. 

23 ‘‘(B) GUIDANCE.—The Secretary shall 

24 issue guidance to hospitals that describes situa25 tions that constitute a state of emergency for 

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1 purposes of the exemption under this para2 graph. 

3 ‘‘(c) DEVELOPMENT AND REEVALUATION OF STAFF4 ING PLAN.— 

5 ‘‘(1) CONSIDERATIONS IN DEVELOPMENT OF

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

7 shall provide for direct care registered nurse-to-pa8 tient ratios above the minimum direct care reg9 istered nurse-to-patient ratios required under sub10 section (b) if appropriate based upon consideration 

11 of the following factors: 

12 ‘‘(A) The number of patients and acuity 

13 level of patients as determined by the applica14 tion of an acuity system (as defined in section 

15 3407(1)), on a shift-by-shift basis. 

16 ‘‘(B) The anticipated admissions, dis17 charges, and transfers of patients during each 

18 shift that impacts direct patient care. 

19 ‘‘(C) Specialized experience required of di20 rect care registered nurses on a particular unit. 

21 ‘‘(D) Staffing levels and services provided 

22 by licensed vocational or practical nurses, li23 censed psychiatric technicians, certified nurse 

24 assistants, or other ancillary staff in meeting 

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1 direct patient care needs not required by a di2 rect care registered nurse. 

3 ‘‘(E) The level and quality of technology 

4 available that affects the delivery of direct pa5 tient care. 

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

7 practices, policies, and procedures by temporary 

8 agency direct care registered nurses used dur9 ing a shift. 

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

11 of patient care presented by physical layout. 

12 ‘‘(2) DOCUMENTATION OF STAFFING.—A hos13 pital shall specify the system used to document ac14 tual staffing in each unit for each shift. 

15 ‘‘(3) ANNUAL REEVALUATION OF PLAN AND

16 ACUITY SYSTEM.— 

17 ‘‘(A) IN GENERAL.—A hospital shall annu18 ally evaluate— 

19 ‘‘(i) its staffing plan in each unit in 

20 relation to actual patient care require21 ments; and 

22 ‘‘(ii) the accuracy of its acuity system. 

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

24 staffing plan and acuity system to the extent 

25 appropriate based on such evaluation. 

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1 ‘‘(4) TRANSPARENCY.— 

2 ‘‘(A) IN GENERAL.—Any acuity-based pa3 tient classification system adopted by a hospital 

4 under this section shall be transparent in all re5 spects, including disclosure of detailed docu6 mentation of the methodology used to predict 

7 nursing staffing, identifying each factor, as8 sumption, and value used in applying such 

9 methodology. 

10 ‘‘(B) PUBLIC AVAILABILITY.—The Sec11 retary shall establish procedures to provide that 

12 the documentation submitted under subsection 

13 (e) is available for public inspection in its en14 tirety. 

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

16 staffing plan of a hospital shall be developed and 

17 subsequent reevaluations shall be conducted under 

18 this subsection on the basis of input from direct care 

19 registered nurses at the hospital or, where such 

20 nurses are represented through collective bargaining, 

21 from the applicable recognized or certified collective 

22 bargaining representative of such nurses. Nothing in 

23 this title shall be construed to permit conduct pro24 hibited under the National Labor Relations Act or 

25 under the Federal Labor Relations Act. 

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1 ‘‘(d) ACUITY TOOL.— 

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

3 after the date of enactment of the National Nursing 

4 Shortage Reform and Patient Advocacy Act, the 

5 Secretary shall develop a national acuity tool that 

6 provides a transparent method for establishing nurse 

7 staffing requirements above the hospital unit direct 

8 care registered nurse-to-patient ratios required 

9 under subsection (b). 

10 ‘‘(2) IMPLEMENTATION.—Each hospital may 

11 adopt and implement the national acuity tool de12 scribed in paragraph (1), and provide staffing based 

13 on such tool. Any additional direct care registered 

14 nursing staffing above the hospital unit direct care 

15 registered nurse-to-patient ratios described in sub16 section (b) shall be assigned in a manner determined 

17 by such national acuity tool. 

18 ‘‘(e) SUBMISSION OF PLAN TO SECRETARY.—A hos19 pital shall submit to the Secretary its staffing plan re20 quired under subsection (a)(1) and any annual updates 

21 under subsection (c)(3)(B). 

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

23 ‘‘(a) POSTING REQUIREMENTS.—In each unit, a hos24 pital shall post a uniform notice in a form specified by 

25 the Secretary in regulation that— 

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1 ‘‘(1) explains requirements imposed under sec2 tion 3401; 

3 ‘‘(2) includes actual direct care registered 

4 nurse-to-patient ratios during each shift; and 

5 ‘‘(3) is visible, conspicuous, and accessible to 

6 staff, patients, and the public. 

7 ‘‘(b) RECORDS.— 

8 ‘‘(1) MAINTENANCE OF RECORDS.—Each hos9 pital shall maintain accurate records of actual direct 

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

11 for each shift for no less than 2 years. Such records 

12 shall include— 

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

14 ‘‘(B) the identity and duty hours of each 

15 direct care registered nurse assigned to each 

16 patient in each unit in each shift; and 

17 ‘‘(C) a copy of each notice posted under 

18 subsection (a). 

19 ‘‘(2) AVAILABILITY OF RECORDS.—Each hos20 pital shall make its records maintained under para21 graph (1) available to— 

22 ‘‘(A) the Secretary; 

23 ‘‘(B) registered nurses and their collective 

24 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 en19 actment of this title, and shall be based on the study con20 ducted under subsection (b). 

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

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

23 the Director of the Agency for Healthcare Research and 

24 Quality, shall complete a study of licensed practical nurse 

25 staffing and its effects on patient care in hospitals. The 

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1 Director may contract with a qualified entity or organiza2 tion to carry out such study under this paragraph. The 

3 Director shall consult with licensed practical nurses and 

4 organizations representing licensed practical nurses re5 garding 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), (5)(A), and (6) of 

9 section 3401(b), section 3401(c), and section 3402 shall 

10 apply to the establishment and application of direct care 

11 licensed practical nurse staffing requirements under this 

12 section in the same manner that they apply to the estab13 lishment and application of direct care registered nurse14 to-patient ratios under sections 3401 and 3402. 

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

16 section shall take effect as soon as practicable, as deter17 mined by the Secretary, but not later than 2 years after 

18 the date of enactment of this title, or in the case of a 

19 hospital in a rural area (as defined in section 

20 1886(d)(2)(D) of the Social Security Act), not later than 

21 4 years after the date of enactment of this title. 

22 ‘‘SEC. 3404. ADJUSTMENT IN REIMBURSEMENT. 

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

24 shall adjust payments made to hospitals under title XVIII 

25 of the Social Security Act in an amount equal to the net 

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1 amount of additional costs incurred in providing services 

2 to Medicare beneficiaries that are attributable to compli3 ance with requirements imposed under sections 3401 

4 through 3403. The amount of such payment adjustments 

5 shall take into account recommendations contained in the 

6 report submitted by the Medicare Payment Advisory Com7 mission under subsection (b). 

8 ‘‘(b) MEDPAC REPORT.—Not later than 2 years 

9 after the date of the enactment of this title, the Medicare 

10 Payment Advisory Commission (established under section 

11 1805 of the Social Security Act) shall submit to Congress 

12 and the Secretary a report estimating total costs and sav13 ings attributable to compliance with requirements imposed 

14 under sections 3401 through 3403. Such report shall in15 clude recommendations on the need, if any, to adjust reim16 bursement for Medicare payments under subsection (a). 

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

18 ‘‘(a) RECOGNITION OF DUTY AND RIGHT OF NURSES

19 TO ADVOCATE IN THE EXCLUSIVE INTEREST OF THE PA20 TIENT.—A nurse shall have the right to act as the pa21 tient’s advocate, as circumstances require, by— 

22 ‘‘(1) initiating action to improve health care or 

23 to change decisions or activities, including the rec24 ommendations of health information technology 

25 tools, which, in the professional judgment of the 

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1 nurse, are against the interests and wishes of the 

2 patient; and 

3 ‘‘(2) giving the patient an opportunity to make 

4 informed decisions about health care before it is pro5 vided. 

6 ‘‘(b) REFUSAL OF ASSIGNMENT.—A nurse may 

7 refuse to accept an assignment as a nurse in a hospital 

8 if— 

9 ‘‘(1) the assignment would violate section 3401 

10 or 3403; or 

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

12 training, or experience to fulfill the assignment with13 out compromising the safety of any patient or jeop14 ardizing the license of the nurse. 

15 ‘‘(c) RETALIATION FOR REFUSAL OF ASSIGNMENT

16 BARRED.— 

17 ‘‘(1) NO DISCHARGE, DISCRIMINATION, OR RE18 TALIATION.—No hospital shall discharge, discrimi19 nate, or retaliate in any manner with respect to any 

20 aspect of employment (as defined in section 

21 3407(5)), including discharge, promotion, compensa22 tion, or terms, conditions, or privileges of employ23 ment against a nurse based on the nurse’s refusal of 

24 a work assignment under subsection (b). 

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

2 shall file a complaint or a report against a nurse 

3 with the appropriate State professional disciplinary 

4 agency because of the nurse’s refusal of a work as5 signment described in subsection (b). 

6 ‘‘(d) CAUSE OF ACTION.—Any nurse who has been 

7 discharged, discriminated against, or retaliated against in 

8 violation of subsection (c)(1) or against whom a complaint 

9 has been filed in violation of subsection (c)(2) may bring 

10 a cause of action in a United States district court. A nurse 

11 who prevails on the cause of action shall be entitled to 

12 one or more of the following: 

13 ‘‘(1) Reinstatement. 

14 ‘‘(2) Reimbursement of lost wages, compensa15 tion, and benefits. 

16 ‘‘(3) Attorneys’ fees. 

17 ‘‘(4) Court costs. 

18 ‘‘(5) Other damages. 

19 ‘‘(e) COMPLAINT TO SECRETARY.— 

20 ‘‘(1) IN GENERAL.—A nurse, patient, or other 

21 individual may file a complaint with the Secretary 

22 against a hospital that violates the provisions of this 

23 title. For any complaint filed, the Secretary shall— 

24 ‘‘(A) receive and investigate the complaint; 

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1 ‘‘(B) determine whether a violation of this 

2 title as alleged in the complaint has occurred; 

3 and 

4 ‘‘(C) if such a violation has occurred, issue 

5 an order that the complaining nurse or indi6 vidual shall not suffer any retaliation described 

7 in subsection (c) or subsection (g). 

8 ‘‘(f) TOLL-FREE TELEPHONE NUMBER.— 

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

10 for the establishment of a toll-free telephone hotline 

11 to provide information regarding the requirements 

12 under section 3401 and to receive reports of viola13 tions of such section. 

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

15 provide each patient admitted to the hospital for in16 patient care with the hotline described in paragraph 

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

18 hotline may be used to report inadequate staffing or 

19 care. 

20 ‘‘(g) PROTECTION FOR REPORTING.— 

21 ‘‘(1) PROHIBITION ON RETALIATION OR DIS22 CRIMINATION.—A hospital shall not discriminate or 

23 retaliate in any manner against any patient, em24 ployee, or contract employee of the hospital, or any 

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

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1 good faith, individually or in conjunction with an2 other person or persons, has presented a grievance 

3 or complaint, or has initiated or cooperated in any 

4 investigation or proceeding of any governmental en5 tity, regulatory agency, or private accreditation 

6 body, made a civil claim or demand, or filed an ac7 tion relating to the care, services, or conditions of 

8 the hospital or of any affiliated or related facilities. 

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

10 this subsection, an individual shall be deemed to be 

11 acting in good faith if the individual reasonably be12 lieves— 

13 ‘‘(A) the information reported or disclosed 

14 is true; and 

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

16 or may occur. 

17 ‘‘(h) PROHIBITION ON INTERFERENCE WITH

18 RIGHTS.— 

19 ‘‘(1) EXERCISE OF RIGHTS.—It shall be unlaw20 ful for any hospital to— 

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

22 exercise, or attempt to exercise, by any person 

23 of any right provided or protected under this 

24 title; or 

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1 ‘‘(B) coerce or intimidate any person re2 garding the exercise or attempt to exercise such 

3 right. 

4 ‘‘(2) OPPOSITION TO UNLAWFUL POLICIES OR

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

6 discriminate or retaliate against any person for op7 posing any hospital policy, practice, or actions which 

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

9 any provision of this title. 

10 ‘‘(3) PROHIBITION ON INTERFERENCE WITH

11 PROTECTED COMMUNICATIONS.—A hospital (or an 

12 individual representing a hospital) shall not make, 

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

14 practice which in any manner directly or indirectly 

15 prohibits, impedes, or discourages a direct care reg16 istered nurse from, or intimidates, coerces, or in17 duces a direct care registered nurse regarding, en18 gaging in free speech activities or disclosing informa19 tion as provided under this title. 

20 ‘‘(4) PROHIBITION ON INTERFERENCE WITH

21 COLLECTIVE ACTION.—A hospital (or an individual 

22 representing a hospital) shall not in any way inter23 fere with the rights of nurses to organize, bargain 

24 collectively, and engage in concerted activity under 

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1 section 7 of the National Labor Relations Act (29 

2 U.S.C. 157). 

3 ‘‘(i) NOTICE.—A hospital shall post in an appropriate 

4 location in each unit a conspicuous notice in a form speci5 fied by the Secretary that— 

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

7 other individuals under this section; 

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

9 or other individual may file a complaint with the 

10 Secretary against a hospital that violates the provi11 sions of this title; and 

12 ‘‘(3) provides instructions on how to file a com13 plaint under paragraph (2). 

14 ‘‘(j) EFFECTIVE DATES.— 

15 ‘‘(1) REFUSAL; RETALIATION; CAUSE OF AC16 TION.— 

17 ‘‘(A) IN GENERAL.—Subsections (b) 

18 through (d) shall apply to refusals occurring on 

19 or after the effective date of the provision to 

20 which the refusal relates. 

21 ‘‘(B) EXCEPTION.—Subsection (b)(2) shall 

22 not apply to refusals in any hospital before the 

23 requirements of section 3401(a) apply to that 

24 hospital. 

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1 ‘‘(2) PROTECTIONS FOR REPORTING.—Sub2 section (g)(1) shall apply to actions occurring on or 

3 after the effective date of the provision to which the 

4 violation relates, except that such subsection shall 

5 apply to initiation, cooperation, or participation in 

6 an investigation or proceeding on or after the date 

7 of enactment of this title. 

8 ‘‘(3) NOTICE.—Subsection (i) shall take effect 

9 18 months after the date of enactment of this title. 

10 ‘‘SEC. 3406. ENFORCEMENT. 

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

12 requirements and prohibitions of this title in accordance 

13 with this section. 

14 ‘‘(b) PROCEDURES FOR RECEIVING AND INVES15 TIGATING COMPLAINTS.—The Secretary shall establish 

16 procedures under which— 

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

18 that a hospital has violated a requirement or a pro19 hibition of this title; and 

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

21 the Secretary. 

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

23 hospital has violated a requirement of this title, the Sec24 retary— 

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1 ‘‘(1) shall require the facility to establish a cor2 rective action plan to prevent the recurrence of such 

3 violation; and 

4 ‘‘(2) may impose civil money penalties, as de5 scribed in subsection (d). 

6 ‘‘(d) CIVIL PENALTIES.— 

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

8 penalties prescribed by law, the Secretary may im9 pose civil penalties as follows: 

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

11 may impose on a hospital found to be in viola12 tion of this title, a civil money penalty of not 

13 more than $25,000 for each knowing violation 

14 of a requirement of this title, except that the 

15 Secretary shall impose a civil money penalty of 

16 more than $25,000 for each such violation in 

17 the case of a participating hospital that the 

18 Secretary determines has a pattern or practice 

19 of such violations (with the amount of such ad20 ditional penalties being determined in accord21 ance with a schedule or methodology specified 

22 in regulations). 

23 ‘‘(B) INDIVIDUAL LIABILITY.—The Sec24 retary may impose on an individual who— 

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

2 by the Secretary to have violated a require3 ment of this title; and 

4 ‘‘(ii) willfully violates this title, 

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

6 for each such violation. 

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

8 1128A of the Social Security Act (other than sub9 sections (a) and (b)) shall apply to a civil money 

10 penalty under this paragraph in the same manner as 

11 such provisions apply to a penalty or proceeding 

12 under such section 1128A. 

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

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

15 publish on the Internet website of the Department 

16 of Health and Human Services the names of partici17 pating hospitals on which civil money penalties have 

18 been imposed under this subsection, the violation for 

19 which such penalty was imposed, and such addi20 tional information as the Secretary determines ap21 propriate. 

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

23 a participating hospital that had a change in owner24 ship, as determined by the Secretary, penalties im25 posed on the hospital while under previous ownermstockstill on DSK4VPTVN1PROD with BILLS

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1 ship shall no longer be published by the Secretary of 

2 such Internet website after the 1-year period begin3 ning on the date of change in ownership. 

4 ‘‘(f) OFFSET.—Funds collected by the Secretary 

5 under this section shall be used to offset the costs of en6 forcing this title. 

7 ‘‘SEC. 3407. DEFINITIONS. 

8 ‘‘For purposes of this title: 

9 ‘‘(1) ACUITY SYSTEM.—The term ‘acuity sys10 tem’ means an established measurement tool that— 

11 ‘‘(A) predicts nursing care requirements 

12 for individual patients based on severity of pa13 tient illness, need for specialized equipment and 

14 technology, intensity of nursing interventions 

15 required, and the complexity of clinical nursing 

16 judgment needed to design, implement, and 

17 evaluate the patient’s nursing care plan; 

18 ‘‘(B) details the amount of nursing care 

19 needed, both in number of nurses and in skill 

20 mix of nursing personnel required, on a daily 

21 basis, for each patient in a nursing department 

22 or unit; 

23 ‘‘(C) takes into consideration the patient 

24 care services provided not only by registered 

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1 nurses but also by direct care licensed practical 

2 nurses and other health care personnel; and 

3 ‘‘(D) is stated in terms that can be readily 

4 used and understood by nurses. 

5 ‘‘(2) DIRECT CARE LICENSED PRACTICAL

6 NURSE.—The term ‘direct care licensed practical 

7 nurse’ means an individual who has been granted a 

8 license by at least 1 State to practice as a licensed 

9 practical nurse or a licensed vocational nurse and 

10 who provides bedside care for 1 or more patients. 

11 ‘‘(3) DIRECT CARE REGISTERED NURSE.—The 

12 term ‘direct care registered nurse’ means an indi13 vidual who has been granted a license by at least 1 

14 State to practice as a registered nurse and who pro15 vides bedside care for 1 or more patients. 

16 ‘‘(4) EMPLOYMENT.—The term ‘employment’ 

17 includes the provision of services under a contract or 

18 other arrangement. 

19 ‘‘(5) HOSPITAL.—The term ‘hospital’ has the 

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

21 Social Security Act and includes a hospital that is 

22 operated by the Department of Veterans Affairs and 

23 a long-term care hospital (as defined in section 

24 1861(ccc) of such Act). 

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1 ‘‘(6) NURSE.—The term ‘nurse’ means any di2 rect care registered nurse or direct care licensed 

3 practical nurse (as the case may be), regardless of 

4 whether or not the nurse is an employee. 

5 ‘‘(7) STAFFING PLAN.—The term ‘staffing plan’ 

6 means a staffing plan required under section 3401. 

7 ‘‘(8) STATE OF EMERGENCY.—The term ‘state 

8 of emergency’ means a state of emergency that is an 

9 unpredictable or unavoidable occurrence at an un10 scheduled or unpredictable interval, relating to 

11 health care delivery and requiring immediate medical 

12 interventions and care, but such term does not in13 clude a state of emergency that results from a labor 

14 dispute in the health care industry or consistent 

15 understaffing. 

16 ‘‘SEC. 3408. RULE OF CONSTRUCTION. 

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

18 disclosure of private and confidential patient information, 

19 except in the case where such disclosure is otherwise re20 quired by law, compelled by proper legal process, con21 sented to by the patient, provided in confidence to regu22 latory or accreditation agencies or other government enti23 ties for investigatory purposes, or provided pursuant to 

24 formal or informal complaints of unlawful or improper 

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1 practices for purposes of achieving corrective and remedial 

2 action.’’. 

3 (b) RECOMMENDATIONS TO CONGRESS.—Not later 

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

5 Secretary of Health and Human Services shall submit to 

6 Congress a report containing recommendations for ensur7 ing that sufficient numbers of nurses are available to meet 

8 the requirements imposed by title XXXIV of the Public 

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

10 (c) REPORT BY HRSA.— 

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

12 the date of enactment of this Act, the Administrator 

13 of the Health Resources and Services Administra14 tion, in consultation with the National Health Care 

15 Workforce Commission, shall submit to Congress a 

16 report regarding the relationship between nurse 

17 staffing levels and nurse retention in hospitals. 

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

19 after the date of enactment of this Act, the Adminis20 trator of the Health Resources and Services Admin21 istration, in consultation with the National Health 

22 Care Workforce Commission, shall submit to Con23 gress an update of the report submitted under para24 graph (1). 

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1 SEC. 3. ENFORCEMENT OF REQUIREMENTS THROUGH FED2 ERAL PROGRAMS. 

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

4 Social Security Act (42 U.S.C. 1395cc(a)(1)) is amend5 ed— 

6 (1) by striking ‘‘and’’ at the end of subpara7 graph (V); 

8 (2) in subparagraph (W), as added by section 

9 3005(1)(C) of the Patient Protection and Affordable 

10 Care Act (Public Law 111–148)— 

11 (A) by moving such subparagraph 2 ems to 

12 the left; and 

13 (B) by striking the period at the end and 

14 inserting a comma; 

15 (3) by redesignating subparagraph (W), as 

16 added by section 6406(b)(3) of the Patient Protec17 tion and Affordable Care Act (Public Law 111–148), 

18 as subparagraph (X) and moving such subparagraph 

19 2 ems to the left; 

20 (4) in subparagraph (X), as redesignated by 

21 paragraph (3), by striking the period at the end and 

22 inserting ‘‘, and’’; and 

23 (5) by inserting after subparagraph (X), as so 

24 redesignated, the following: 

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1 ‘‘(Y) in the case of a hospital, to be subject to 

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) in paragraph (82)(C), by striking ‘‘and’’ at 

7 the end; 

8 (2) in paragraph (83), by striking the period at 

9 the end and inserting ‘‘; and’’; and 

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

12 ‘‘(84) provide that any hospital receiving pay13 ments under such plan shall be subject to the provi14 sions of title XXXIV of the Public Health Service 

15 Act.’’. 

16 (c) HEALTH BENEFITS PROGRAM OF THE DEPART17 MENT OF VETERANS AFFAIRS.—Section 8110(a) of title 

18 38, United States Code, is amended by adding at the end 

19 the following: 

20 ‘‘(7) Subject to appropriations, the Secretary of 

21 Veterans Affairs may require that a Department 

22 medical facility that is a 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) AUTHORIZATION OF APPROPRIATIONS.—There 

8 are authorized to be appropriated to the Secretary of Vet9 erans Affairs, for compliance with title XXXIV of the 

10 Public Health Service Act pursuant to section 8110(a)(7) 

11 of title 38, United States Code, such sums as may be nec12 essary for fiscal year 2014 and each subsequent fiscal 

13 year. 

14 SEC. 4. NURSE WORKFORCE INITIATIVE. 

15 (a) SCHOLARSHIP AND STIPEND PROGRAM.—Section 

16 846(d) of the Public Health Service Act (42 U.S.C. 

17 297n(d)) is amended— 

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

19 STIPEND’’ after ‘‘SCHOLARSHIP’’; and 

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

21 after ‘‘scholarships’’. 

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

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

24 is amended— 

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

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

3 RETENTION.—’’; 

4 (2) in paragraph (2), by striking ‘‘; or’’ and in5 serting a semicolon; 

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

7 inserting a semicolon; and 

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

9 ‘‘(4) to provide additional support to nurses en10 tering the workforce by implementing nursing pre11 ceptorship projects that establish a period of prac12 tical and clinical experiences and training for nurs13 ing students, newly hired nurses, and recent grad14 uates of a direct care degree programs for registered 

15 nurses; or 

16 ‘‘(5) to implement mentorship projects that as17 sist new or transitional direct care registered nurses 

18 in adapting to the hospital setting.’’. 

Æ 

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