I 

112TH CONGRESS 

1ST SESSION H. R. 2187 

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 HOUSE OF REPRESENTATIVES 

JUNE 15, 2011 

Ms. SCHAKOWSKY (for herself, Mr. STARK, Mr. ELLISON, Ms. LEE of California, Ms. DELAURO, Ms. BALDWIN, Mr. RANGEL, Ms. EDDIE BERNICE

JOHNSON of Texas, Mr. RYAN of Ohio, Mr. LYNCH, Ms. NORTON, and 

Mr. SHERMAN) 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 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; FINDINGS. 

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

5 ‘‘Nurse Staffing Standards for Patient Safety and Quality 

6 Care Act of 2011’’. 


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1 (b) 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 2002 Joint 

19 Commission on Accreditation of Healthcare Organi20 zations report that concluded that the lack of direct 

21 care registered nurses contributed to nearly a quar22 ter of the unanticipated problems that result in in23 jury or death to hospital patients. 

24 (5) Requirements for direct care registered 

25 nurse staffing ratios will help address the registered 


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1 nurse shortage in the United States by aiding in re2 cruitment of new registered nurses and improving 

3 retention of registered nurses who are considering 

4 leaving direct patient care because of demands cre5 ated by inadequate staffing. 

6 (6) Establishing adequate minimum direct care 

7 registered nurse-to-patient ratios that take into ac8 count patient acuity measures will improve the deliv9 ery of quality health care services and guarantee pa10 tient safety. 

11 (7) Establishing safe staffing standards for di12 rect care registered nurses is a critical component of 

13 assuring that there is adequate hospital staffing at 

14 all levels to improve the delivery of quality care and 

15 protect patient safety. 

16 SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE 

17 STAFFING REQUIREMENT. 

18 (a) MINIMUM DIRECT CARE REGISTERED NURSE

19 STAFFING REQUIREMENTS.—The Public Health Service 

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

21 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 not later than 1 year after the date of the 

19 enactment of this title. 

20 ‘‘(B) APPLICATION OF MINIMUM DIRECT

21 CARE REGISTERED NURSE-TO-PATIENT RA22 TIOS.—The requirements under subsection (b) 

23 shall take effect as soon as practicable, as de24 termined by the Secretary, but not later than 2 

25 years after the date of the enactment of this 


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1 title, or in the case of a hospital in a rural area 

2 (as defined in section 1886(d)(2)(D) of the So3 cial Security Act), not later than 4 years after 

4 the date of the enactment of this title. 

5 ‘‘(b) MINIMUM DIRECT CARE REGISTERED NURSE6 TO-PATIENT RATIOS.— 

7 ‘‘(1) IN GENERAL.—Except as provided in para8 graph (4) and other provisions of this section, a hos9 pital’s staffing plan shall provide that, at all times 

10 during each shift within a unit of the hospital, a di11 rect care registered nurse may be assigned to not 

12 more than the following number of patients in that 

13 unit: 

14 ‘‘(A) One patient in trauma emergency 

15 units. 

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

17 provided that a minimum of 1 additional person 

18 serves as a scrub assistant in such unit. 

19 ‘‘(C) Two patients in critical care units, in20 cluding neonatal intensive care units, emer21 gency critical care and intensive care units, 

22 labor and delivery units, coronary care units, 

23 acute respiratory care units, postanesthesia 

24 units, and burn units. 


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1 ‘‘(D) Three patients in emergency room 

2 units, pediatrics units, stepdown units, telem3 etry units, antepartum units, and combined 

4 labor, deliver, and postpartum units. 

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

6 units, intermediate care nursery units, acute 

7 care psychiatric units, and other specialty care 

8 units. 

9 ‘‘(F) Five patients in rehabilitation units 

10 and skilled nursing units. 

11 ‘‘(G) Six patients in postpartum (3 cou12 plets) units and well-baby nursery units. 

13 ‘‘(2) SIMILAR UNITS WITH DIFFERENT

14 NAMES.—The Secretary may apply minimum direct 

15 care registered nurse-to-patient ratios established in 

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

17 paragraph to a type of hospital unit not referred to 

18 in such paragraph if such type of hospital unit pro19 vides a level of care to patients whose needs are 

20 similar to the needs of patients cared for in the hos21 pital unit referred to in such paragraph. 

22 ‘‘(3) RESTRICTIONS.— 

23 ‘‘(A) PROHIBITION AGAINST AVERAGING.— 

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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) RELATIONSHIP TO STATE-IMPOSED RA8 TIOS.—Nothing in this title shall preempt State 

9 standards that the Secretary determines to be at 

10 least equivalent to Federal requirements for a staff11 ing plan established under this title. Minimum direct 

12 care registered nurse-to-patient ratios established 

13 under this subsection shall not preempt State re14 quirements 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.—The re18 quirements established under this subsection shall 

19 not apply during a state of emergency if a hospital 

20 is requested or expected to provide an exceptional 

21 level of emergency or other medical services. The 

22 Secretary shall issue guidance to hospitals that de23 scribes situations that constitute a state of emer24 gency for purposes of the exemption under this para25 graph. 


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1 ‘‘(c) DEVELOPMENT AND REEVALUATION OF STAFF2 ING PLAN.— 

3 ‘‘(1) CONSIDERATIONS IN DEVELOPMENT OF

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

5 shall provide for direct care registered nurse-to-pa6 tient ratios above the minimum direct care reg7 istered nurse-to-patient ratios required under sub8 section (b) if appropriate based upon consideration 

9 of the following factors: 

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

11 level of patients as determined by the applica12 tion of an acuity system (as defined in section 

13 3406(1)), on a shift-by-shift basis. 

14 ‘‘(B) The anticipated admissions, dis15 charges, and transfers of patients during each 

16 shift that impacts direct patient care. 

17 ‘‘(C) Specialized experience required of di18 rect care registered nurses on a particular unit. 

19 ‘‘(D) Staffing levels and services provided 

20 by licensed vocational or practical nurses, li21 censed psychiatric technicians, certified nurse 

22 assistants, or other ancillary staff in meeting 

23 direct patient care needs not required by a di24 rect care registered nurse. 


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1 ‘‘(E) The level of technology available that 

2 affects the delivery of direct patient care. 

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

4 practices, policies, and procedures by temporary 

5 agency direct care registered nurses used dur6 ing a shift. 

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

8 of patient care presented by physical layout. 

9 ‘‘(2) DOCUMENTATION OF STAFFING.—A hos10 pital shall specify the system used to document ac11 tual staffing in each unit for each shift. 

12 ‘‘(3) ANNUAL REEVALUATION OF PLAN AND

13 ACUITY SYSTEM.— 

14 ‘‘(A) IN GENERAL.—A hospital shall annu15 ally evaluate— 

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

17 relation to actual patient care require18 ments; and 

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

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

21 staffing plan and acuity system to the extent 

22 appropriate based on such evaluation. 

23 ‘‘(4) TRANSPARENCY.— 

24 ‘‘(A) IN GENERAL.—Any acuity-based pa25 tient classification system adopted by a hospital 


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1 under this section shall be transparent in all re2 spects, including disclosure of detailed docu3 mentation of the methodology used to predict 

4 nursing staffing, identifying each factor, as5 sumption, and value used in applying such 

6 methodology. 

7 ‘‘(B) PUBLIC AVAILABILITY.—The Sec8 retary shall establish procedures to provide that 

9 the documentation submitted under subsection 

10 (e) is available for public inspection in its en11 tirety. 

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

13 staffing plan of a hospital shall be developed and 

14 subsequent reevaluations shall be conducted under 

15 this subsection on the basis of input from direct care 

16 registered nurses at the hospital or, where such 

17 nurses are represented through collective bargaining, 

18 from the applicable recognized or certified collective 

19 bargaining representative of such nurses. Nothing in 

20 this title shall be construed to permit conduct pro21 hibited under the National Labor Relations Act or 

22 under the Federal Labor Relations Act. 

23 ‘‘(d) ACUITY TOOL.— 

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

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1 retary shall develop a process to establish a national 

2 acuity tool that provides a transparent method for 

3 establishing nurse staffing requirements that exceed 

4 the minimum hospital unit direct care registered 

5 nurse-to-patient ratios required under subsection 

6 (b). 

7 ‘‘(2) IMPLEMENTATION.—Each hospital unit 

8 shall adopt and implement the national acuity tool 

9 described in paragraph (1), and provide staffing 

10 based on such tool. Any additional direct care reg11 istered nursing staffing above the hospital unit di12 rect care registered nurse-to-patient ratios described 

13 in subsection (b) shall be assigned in a manner de14 termined by such national acuity tool. 

15 ‘‘(e) SUBMISSION OF PLAN TO SECRETARY.—A hos16 pital shall submit to the Secretary its staffing plan and 

17 any annual updates under subsection (c)(3)(B). A feder18 ally operated hospital may submit its staffing plan 

19 through the department or agency operating the hospital. 

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

21 ‘‘(a) POSTING REQUIREMENTS.—In each unit, a hos22 pital shall post a uniform notice in a form specified by 

23 the Secretary in regulation that— 

24 ‘‘(1) explains requirements imposed under sec25 tion 3401; 


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1 ‘‘(2) includes actual direct care registered 

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

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

4 staff, patients, and the public. 

5 ‘‘(b) RECORDS.— 

6 ‘‘(1) MAINTENANCE OF RECORDS.—Each hos7 pital shall maintain accurate records of actual direct 

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

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

10 shall include— 

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

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

13 direct care registered nurse assigned to each 

14 patient in each unit in each shift; and 

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

16 subsection (a). 

17 ‘‘(2) AVAILABILITY OF RECORDS.—Each hos18 pital shall make its records maintained under para19 graph (1) available to— 

20 ‘‘(A) the Secretary; 

21 ‘‘(B) registered nurses and their collective 

22 bargaining representatives (if any); and 

23 ‘‘(C) the public under regulations estab24 lished by the Secretary, or in the case of a fed25 erally operated hospital, under section 552 of 


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1 title 5, United States Code (commonly known 

2 as the ‘Freedom of Information Act’). 

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

4 audits to ensure— 

5 ‘‘(1) implementation of the staffing plan in ac6 cordance with this title; and 

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

8 section. 

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

10 NURSE STAFFING REQUIREMENTS. 

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

12 shall comply with minimum direct care licensed practical 

13 nurse staffing requirements that the Secretary establishes 

14 for units in hospitals. Such staffing requirements shall be 

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

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

17 conducted under subsection (b). 

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

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

20 through the Director of the Agency for Healthcare Re21 search and Quality, shall complete a study of licensed 

22 practical nurse staffing and its effects on patient care in 

23 hospitals. The Director may contract with a qualified enti24 ty or organization to carry out such study under this para25 graph. The Director shall consult with licensed practical 


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1 nurses and organizations representing licensed practical 

2 nurses regarding the design and conduct of the study. 

3 ‘‘(c) APPLICATION OF REGISTERED NURSE PROVI4 SIONS TO LICENSED PRACTICAL NURSE STAFFING RE5 QUIREMENTS.—Paragraphs (2), (3), (4)(A), and (5) of 

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

7 apply to the establishment and application of direct care 

8 licensed practical nurse staffing requirements under this 

9 section in the same manner that they apply to the estab10 lishment and application of direct care registered nurse11 to-patient ratios under sections 3401 and 3402. 

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

13 section shall take effect as soon as practicable, as deter14 mined by the Secretary, but not later than 2 years after 

15 the date of the enactment of this title, or in the case of 

16 a hospital in a rural area (as defined in section 

17 1886(d)(2)(D) of the Social Security Act), not later than 

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

19 ‘‘SEC. 3404. ADJUSTMENT IN REIMBURSEMENT. 

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

21 shall adjust payments made to hospitals (other than feder22 ally operated hospitals) under title XVIII of the Social Se23 curity Act in an amount equal to the net amount of addi24 tional costs incurred in providing services to Medicare 

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1 quirements imposed under sections 3401 through 3403. 

2 The amount of such payment adjustments shall take into 

3 account recommendations contained in the report sub4 mitted by the Medicare Payment Advisory Commission 

5 under subsection (c). 

6 ‘‘(b) AUTHORIZATION OF APPROPRIATION FOR FED7 ERALLY OPERATED HOSPITALS.—There are authorized to 

8 be appropriated such additional sums as are required for 

9 federally operated hospitals to comply with the additional 

10 requirements established under sections 3401 through 

11 3403. 

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

13 the date of the enactment of this title, the Medicare Pay14 ment Advisory Commission (established under section 

15 1805 of the Social Security Act) shall submit to Congress 

16 and the Secretary a report estimating total costs and sav17 ings attributable to compliance with requirements imposed 

18 under sections 3401 through 3403. Such report shall in19 clude recommendations on the need, if any, to adjust reim20 bursement for Medicare payments under subsection (a). 

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

22 ‘‘(a) OBJECTION TO OR REFUSAL OF ASSIGNMENT.— 

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

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

25 faith— 


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

2 violation of section 3401 or 3403; or 

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

4 training, or experience to fulfill the assignment with5 out compromising the safety of any patient or jeop6 ardizing the license of the nurse. 

7 ‘‘(b) RETALIATION FOR OBJECTION TO OR REFUSAL

8 OF ASSIGNMENT BARRED.— 

9 ‘‘(1) NO DISCHARGE, DISCRIMINATION, OR RE10 TALIATION.—No hospital shall discharge, retaliate, 

11 discriminate, or otherwise take adverse action in any 

12 manner with respect to any aspect of a nurse’s em13 ployment (as defined in section 3407(4)), including 

14 discharge, promotion, compensation, or terms, condi15 tions, or privileges of employment, based on the 

16 nurse’s refusal of a work assignment under sub17 section (a). 

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

19 shall file a complaint or a report against a nurse 

20 with a State professional disciplinary agency because 

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

22 subsection (a). 

23 ‘‘(c) CAUSE OF ACTION.—Any nurse who has been 

24 discharged, discriminated against, or retaliated against in 

25 violation of subsection (b)(1) or against whom a complaint 


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1 or report has been filed in violation of subsection (b)(2) 

2 may (without regard to whether a complaint has been filed 

3 under subsection (d) of this section or subsection (b) of 

4 section 3406) bring a cause of action in a United States 

5 district court. A nurse who prevails on the cause of action 

6 shall be entitled to one or more 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 ‘‘(d) COMPLAINT TO SECRETARY.—A nurse, patient, 

14 or other individual may file a complaint with the Secretary 

15 against a hospital that violates the provisions of this title. 

16 For any complaint filed, the Secretary shall— 

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

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

19 as alleged in the complaint has occurred; and 

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

21 order that the complaining nurse or individual shall 

22 not suffer any discharge, retaliation, discrimination, 

23 or other adverse action prohibited by subsection (b) 

24 or subsection (f). 

25 ‘‘(e) TOLL-FREE TELEPHONE NUMBER.— 


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

2 for the establishment of a toll-free telephone hotline 

3 to provide information regarding the requirements 

4 under sections 3401 through 3403 and to receive re5 ports of violations of such section. 

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

7 provide each patient admitted to the hospital for in8 patient care with the hotline described in paragraph 

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

10 hotline may be used to report inadequate staffing or 

11 care. 

12 ‘‘(f) PROTECTION FOR REPORTING.— 

13 ‘‘(1) PROHIBITION ON RETALIATION OR DIS14 CRIMINATION.—A hospital shall not discriminate or 

15 retaliate in any manner against any patient, em16 ployee, or contract employee of the hospital, or any 

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

18 good faith, individually or in conjunction with an19 other person or persons, has presented a grievance 

20 or complaint, or has initiated or cooperated in any 

21 investigation or proceeding of any governmental en22 tity, regulatory agency, or private accreditation 

23 body, made a civil claim or demand, or filed an ac24 tion relating to the care, services, or conditions of 

25 the hospital or of any affiliated or related facilities. 


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1 ‘‘(2) GOOD FATH DEFINED.—For purposes of 

2 this subsection, an individual shall be deemed to be 

3 acting in good faith if the individual reasonably be4 lieves— 

5 ‘‘(A) the information reported or disclosed 

6 is true; and 

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

8 or may occur. 

9 ‘‘(g) PROHIBITION ON INTERFERENCE WITH

10 RIGHTS.— 

11 ‘‘(1) EXERCISE OF RIGHTS.—It shall be unlaw12 ful for any hospital to— 

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

14 exercise, or attempt to exercise, by any person 

15 of any right provided or protected under this 

16 title; or 

17 ‘‘(B) coerce or intimidate any person re18 garding the exercise or attempt to exercise such 

19 right. 

20 ‘‘(2) OPPOSITION TO UNLAWFUL POLICIES OR

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

22 discriminate or retaliate against any person for op23 posing any hospital policy, practice, or actions which 

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

25 any provision of this title. 


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1 ‘‘(3) PROHIBITION ON INTERFERENCE WITH

2 PROTECTED COMMUNICATIONS.—A hospital (or an 

3 individual representing a hospital) shall not make, 

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

5 practice which in any manner directly or indirectly 

6 prohibits, impedes, or discourages a direct care 

7 nurse from, or intimidates, coerces, or induces a di8 rect care nurse regarding, engaging in free speech 

9 activities or disclosing information as provided under 

10 this title. 

11 ‘‘(4) PROHIBITION ON INTERFERENCE WITH

12 COLLECTIVE ACTION.—A hospital (or an individual 

13 representing a hospital) shall not in any way inter14 fere with the rights of nurses to organize, bargain 

15 collectively, and engage in concerted activity under 

16 section 7 of the National Labor Relations Act (29 

17 U.S.C. 157). 

18 ‘‘(h) NOTICE.—A hospital shall post in an appro19 priate location in each unit a conspicuous notice in a form 

20 specified by the Secretary that— 

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

22 other individuals under this section; 

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

24 or other individual may file a complaint with the 


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1 Secretary against a hospital that violates the provi2 sions of this title; and 

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

4 complaint. 

5 ‘‘(i) EFFECTIVE DATE.— 

6 ‘‘(1) REFUSAL; RETALIATION; CAUSE OF AC7 TION.— 

8 ‘‘(A) IN GENERAL.—Subsections (a) 

9 through (c) shall apply to objections and refus10 als occurring on or after the effective date of 

11 the provision of this title to which the objection 

12 or refusal relates. 

13 ‘‘(B) EXCEPTION.—Subsection (a)(2) shall 

14 not apply to objections or refusals in any hos15 pital before the requirements of section 3401(a) 

16 or 3403(a), as applicable, apply to that hos17 pital. 

18 ‘‘(2) PROTECTIONS FOR REPORTING.—Sub19 section (f)(1) shall apply to actions occurring on or 

20 after the effective date of the provision to which the 

21 violation relates, except that such subsection shall 

22 apply to initiation, cooperation, or participation in 

23 an investigation or proceeding on or after the date 

24 of enactment of this title. 


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1 ‘‘(3) NOTICE.—Subsection (h) shall take effect 

2 18 months after the date of enactment of this title. 

3 ‘‘SEC. 3406. ENFORCEMENT. 

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

5 requirements and prohibitions of this title in accordance 

6 with this section. 

7 ‘‘(b) PROCEDURES FOR RECEIVING AND INVES8 TIGATING COMPLAINTS.—The Secretary shall establish 

9 procedures under which— 

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

11 that a hospital has violated a requirement or a pro12 hibition of this title; and 

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

14 the Secretary. 

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

16 hospital has violated a requirement of this title, the Sec17 retary— 

18 ‘‘(1) shall require the facility to establish a cor19 rective action plan to prevent the recurrence of such 

20 violation; and 

21 ‘‘(2) may impose civil money penalties, as de22 scribed in subsection (d). 

23 ‘‘(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 not 

7 more than $25,000 for each knowing violation 

8 of a requirement of this title, except that the 

9 Secretary shall impose a civil money penalty of 

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

11 the case of a participating hospital that the 

12 Secretary determines has a pattern or practice 

13 of such violations (with the amount of such ad14 ditional penalties being determined in accord15 ance with a schedule or methodology specified 

16 in regulations). 

17 ‘‘(B) INDIVIDUAL LIABILITY.—The Sec18 retary may impose on an individual who— 

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

20 by the Secretary to have violated a require21 ment of this title; and 

22 ‘‘(ii) willfully violates this title, 

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

24 for each such violation. 


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

2 1128A of the Social Security Act (other than sub3 sections (a) and (b)) shall apply to a civil money 

4 penalty under this paragraph in the same manner as 

5 such provisions apply to a penalty or proceeding 

6 under such section 1128A. 

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

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

9 publish on the Internet website of the Department 

10 of Health and Human Services the names of partici11 pating hospitals on which civil money penalties have 

12 been imposed under this subsection, the violation for 

13 which such penalty was imposed, and such addi14 tional information as the Secretary determines ap15 propriate. 

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

17 a participating hospital that had a change of owner18 ship, as determined by the Secretary, penalties im19 posed on the hospital while under previous owner20 ship shall no longer be published by the Secretary of 

21 such Internet website after the 1-year period begin22 ning on the date of change of ownership. 

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

24 under this section shall be used to offset the costs of en25 forcing this title. 


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1 ‘‘SEC. 3407. DEFINITIONS. 

2 ‘‘For purposes of this title: 

3 ‘‘(1) ACUITY SYSTEM.—The term ‘acuity sys4 tem’ means an established measurement tool that— 

5 ‘‘(A) predicts nursing care requirements 

6 for individual patients based on severity of pa7 tient illness, need for specialized equipment and 

8 technology, intensity of nursing interventions 

9 required, and the complexity of clinical nursing 

10 judgment needed to design, implement, and 

11 evaluate the patient’s nursing care plan; 

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

13 needed, both in number of nurses and in skill 

14 mix of nursing personnel required, on a daily 

15 basis, for each patient in a nursing department 

16 or unit; 

17 ‘‘(C) takes into consideration the patient 

18 care services provided not only by registered 

19 nurses but also by direct care licensed practical 

20 nurses and other health care personnel; and 

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

22 used and understood by nurses. 

23 ‘‘(2) DIRECT CARE LICENSED PRACTICAL

24 NURSE.—The term ‘direct care licensed practical 

25 nurse’ means an individual who has been granted a 

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


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1 practical nurse or a licensed vocational nurse and 

2 who provides bedside care for 1 or more patients. 

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

4 term ‘direct care registered nurse’ means an indi5 vidual who has been granted a license by at least 1 

6 State to practice as a registered nurse and who pro7 vides bedside care for 1 or more patients. 

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

9 includes the provision of services under a contract or 

10 other arrangement. 

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

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

13 Social Security Act, and includes a hospital that is 

14 operated by the Department of Veterans Affairs, the 

15 Department of Defense, the Indian Health Services 

16 Program, or any other department or agency of the 

17 United States. 

18 ‘‘(6) NURSE.—The term ‘nurse’ means any di19 rect care registered nurse or direct care licensed 

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

21 whether or not the nurse is an employee. 

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

23 means a staffing plan required under section 3401. 

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

25 of emergency’— 


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

2 an unpredictable or unavoidable occurrence at 

3 an unscheduled or unpredictable interval, relat4 ing to health care delivery and requiring imme5 diate medical interventions and care; and 

6 ‘‘(B) does not include a state emergency 

7 that results from a labor dispute in the health 

8 care industry or consistent understaffing. 

9 ‘‘SEC. 3408. RULE OF CONSTRUCTION. 

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

11 disclosure of private and confidential patient information, 

12 except in the case where such disclosure is otherwise re13 quired by law, compelled by proper legal process, con14 sented to by the patient, provided in confidence to regu15 latory or accreditation agencies or other government enti16 ties for investigatory purposes, or provided pursuant to 

17 formal or informal complaints of unlawful or improper 

18 practices for purposes of achieving corrective and remedial 

19 action.’’. 

20 (b) RECOMMENDATIONS TO CONGRESS.—Not later 

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

22 Secretary of Health and Human Services shall submit to 

23 Congress a report containing recommendations for ensur24 ing that sufficient numbers of nurses are available to meet 


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1 the requirements imposed by title XXXIV of the Public 

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

3 (c) REPORT BY HRSA.— 

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

5 the date of enactment of this Act, the Administrator 

6 of the Health Resources and Services Administra7 tion, in consultation with the National Health Care 

8 Workforce Commission, shall submit to Congress a 

9 report regarding the relationship between nurse 

10 staffing levels and nurse retention in hospitals. 

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

12 after the date of enactment of this Act, the Adminis13 trator of the Health Resources and Services Admin14 istration, in consultation with the National Health 

15 Care Workforce Commission, shall submit to Con16 gress an update of the report submitted under para17 graph (1). 

18 SEC. 3. ENFORCEMENT OF REQUIREMENTS THROUGH FED19 ERAL PROGRAMS. 

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

21 Social Security Act (42 U.S.C. 1395cc(a)(1)) is amend22 ed— 

23 (1) by striking ‘‘and’’ at the end of subpara24 graph (V); 


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1 (2) by striking the period at the end of the sub2 paragraph (W) added by section 3005(1)(C) of Pub3 lic Law 111–148 and inserting a semicolon; 

4 (3) by striking the period at the end of the sub5 paragraph (W) added by section 6406(b)(3) of Pub6 lic Law 111–148 and inserting ‘‘; and’’; and 

7 (4) by inserting after the subparagraph (W) 

8 added by such section 6406(b)(3) the following: 

9 ‘‘(W) in the case of a hospital, to comply 

10 with the provisions of title XXXIV of the Public 

11 Health Service Act.’’. 

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

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

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

15 (82)(C); 

16 (2) by striking the period at the end of para17 graph (83) and inserting ‘‘; and’’; and 

18 (3) by inserting after paragraph (83) the fol19 lowing new paragraph: 

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

21 payment under such plan comply with the provisions 

22 of title XXXIV of the Public Health Service Act (re23 lating to minimum direct care registered nurse staff24 ing requirements).’’. 


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1 (c) HEALTH BENEFITS PROGRAM OF THE DEPART2 MENT OF VETERANS AFFAIRS.—Section 8110(a) of title 

3 38, United States Code, is amended by adding at the end 

4 the following new paragraphs: 

5 ‘‘(7) In the case of a Department medical facility that 

6 is a hospital, the hospital shall comply with the provisions 

7 of title XXXIV of the Public Health Service Act. 

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

9 section 7106 of title 5 shall preclude enforcement of the 

10 provisions of title XXXIV of the Public Health Service Act 

11 with respect to a Department hospital through grievance 

12 procedures negotiated in accordance with chapter 71 of 

13 title 5.’’. 

14 (d) HEALTH BENEFITS PROGRAM OF THE DEPART15 MENT OF DEFENSE.— 

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

17 United States Code, is amended by adding at the 

18 end the following new section: 

19 ‘‘§ 1110c. Staffing requirements 

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

21 that is a hospital, the hospital shall comply with the provi22 sions of title XXXIV of the Public Health Service Act.’’. 

23 (2) CLERICAL AMENDMENT.—The table of sec24 tions at the beginning of such chapter is amended 


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1 by inserting after the item relating to section 1110b 

2 the following new item: 

‘‘1110c. Staffing requirements’’. 

3 (e) INDIAN HEALTH SERVICES PROGRAM.—Title 

4 VIII of the Indian Health Care Improvement Act (25 

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

6 the following new section: 

7 ‘‘SEC. 833. STAFFING REQUIREMENTS. 

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

9 provisions of title XXXIV of the Public Health Service Act 

10 (relating to minimum direct care registered nurse staffing 

11 requirements).’’. 

12 (f) FEDERAL LABOR-MANAGEMENT RELATIONS.— 

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

14 United States Code, is amended by adding at the 

15 end the following: 

16 ‘‘(c) Nothing in this section shall preclude enforce17 ment of the provisions of title XXXIV of the Public Health 

18 Service Act through grievance procedures negotiated in ac19 cordance with section 7121.’’. 

20 (2) CONFORMING AMENDMENT.—Section 

21 7106(a) of title 5, United States Code, is amended 

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

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

Æ 


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