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[Congressional Bills 112th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2187 Introduced in House (IH)]

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.

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

SECTION 1. SHORT TITLE; FINDINGS.

    (a) Short Title.--This Act may be cited as the ``Nurse Staffing 
Standards for Patient Safety and Quality Care Act of 2011''.
    (b) Findings.--Congress finds the following:
            (1) The Federal Government has a substantial interest in 
        promoting quality care and improving the delivery of health 
        care services to patients in health care facilities in the 
        United States.
            (2) Recent changes in health care delivery systems that 
        have resulted in higher acuity levels among patients in health 
        care facilities increase the need for improved quality measures 
        in order to protect patient care and reduce the incidence of 
        medical errors.
            (3) Inadequate and poorly monitored registered nurse 
        staffing practices that result in too few registered nurses 
        providing direct care jeopardize the delivery of quality health 
        care services.
            (4) Numerous studies have shown that patient outcomes are 
        directly correlated to direct care registered nurse staffing 
        levels, including a 2002 Joint Commission on Accreditation of 
        Healthcare Organizations report that concluded that the lack of 
        direct care registered nurses contributed to nearly a quarter 
        of the unanticipated problems that result in injury or death to 
        hospital patients.
            (5) Requirements for direct care registered nurse staffing 
        ratios will help address the registered nurse shortage in the 
        United States by aiding in recruitment of new registered nurses 
        and improving retention of registered nurses who are 
        considering leaving direct patient care because of demands 
        created by inadequate staffing.
            (6) Establishing adequate minimum direct care registered 
        nurse-to-patient ratios that take into account patient acuity 
        measures will improve the delivery of quality health care 
        services and guarantee patient safety.
            (7) Establishing safe staffing standards for direct care 
        registered nurses is a critical component of assuring that 
        there is adequate hospital staffing at all levels to improve 
        the delivery of quality care and protect patient safety.

SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE STAFFING REQUIREMENT.

    (a) Minimum Direct Care Registered Nurse Staffing Requirements.--
The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by 
adding at the end the following new title:

     ``TITLE XXXIV--MINIMUM DIRECT CARE REGISTERED NURSE STAFFING 
                              REQUIREMENT

``SEC. 3401. MINIMUM NURSE STAFFING REQUIREMENT.

    ``(a) Staffing Plan.--
            ``(1) In general.--A hospital shall implement a staffing 
        plan that--
                    ``(A) provides adequate, appropriate, and quality 
                delivery of health care services and protects patient 
                safety; and
                    ``(B) is consistent with the requirements of this 
                title.
            ``(2) Effective dates.--
                    ``(A) Implementation of staffing plan.--Subject to 
                subparagraph (B), the requirements under paragraph (1) 
                shall take effect not later than 1 year after the date 
                of the enactment of this title.
                    ``(B) Application of minimum direct care registered 
                nurse-to-patient ratios.--The requirements under 
                subsection (b) shall take effect as soon as 
                practicable, as determined by the Secretary, but not 
                later than 2 years after the date of the enactment of 
                this title, or in the case of a hospital in a rural 
                area (as defined in section 1886(d)(2)(D) of the Social 
                Security Act), not later than 4 years after the date of 
                the enactment of this title.
    ``(b) Minimum Direct Care Registered Nurse-to-Patient Ratios.--
            ``(1) In general.--Except as provided in paragraph (4) and 
        other provisions of this section, a hospital's staffing plan 
        shall provide that, at all times during each shift within a 
        unit of the hospital, a direct care registered nurse may be 
        assigned to not more than the following number of patients in 
        that unit:
                    ``(A) One patient in trauma emergency units.
                    ``(B) One patient in operating room units, provided 
                that a minimum of 1 additional person serves as a scrub 
                assistant in such unit.
                    ``(C) Two patients in critical care units, 
                including neonatal intensive care units, emergency 
                critical care and intensive care units, labor and 
                delivery units, coronary care units, acute respiratory 
                care units, postanesthesia units, and burn units.
                    ``(D) Three patients in emergency room units, 
                pediatrics units, stepdown units, telemetry units, 
                antepartum units, and combined labor, deliver, and 
                postpartum units.
                    ``(E) Four patients in medical-surgical units, 
                intermediate care nursery units, acute care psychiatric 
                units, and other specialty care units.
                    ``(F) Five patients in rehabilitation units and 
                skilled nursing units.
                    ``(G) Six patients in postpartum (3 couplets) units 
                and well-baby nursery units.
            ``(2) Similar units with different names.--The Secretary 
        may apply minimum direct care registered nurse-to-patient 
        ratios established in paragraph (1) for a hospital unit 
        referred to in such paragraph to a type of hospital unit not 
        referred to in such paragraph if such type of hospital unit 
        provides a level of care to patients whose needs are similar to 
        the needs of patients cared for in the hospital unit referred 
        to in such paragraph.
            ``(3) Restrictions.--
                    ``(A) Prohibition against averaging.--A hospital 
                shall not average the number of patients and the total 
                number of direct care registered nurses assigned to 
                patients in a hospital unit during any 1 shift or over 
                any period of time for purposes of meeting the 
                requirements under this subsection.
                    ``(B) Prohibition against imposition of mandatory 
                overtime requirements.--A hospital shall not impose 
                mandatory overtime requirements to meet the hospital 
                unit direct care registered nurse-to-patient ratios 
                required under this subsection.
                    ``(C) Relief during routine absences.--A hospital 
                shall ensure that only a direct care registered nurse 
                may relieve another direct care registered nurse during 
                breaks, meals, and other routine, expected absences 
                from a hospital unit.
            ``(4) Adjustment of ratios.--
                    ``(A) In general.--If necessary to protect patient 
                safety, the Secretary may prescribe regulations that--
                            ``(i) increase minimum direct care 
                        registered nurse-to-patient ratios under this 
                        subsection to further limit the number of 
                        patients that may be assigned to each direct 
                        care nurse; or
                            ``(ii) add minimum direct care registered 
                        nurse-to-patient ratios for units not referred 
                        to in paragraphs (1) and (2).
                    ``(B) Consultation.--Such regulations shall be 
                prescribed after consultation with affected hospitals 
                and registered nurses.
            ``(5) Relationship to state-imposed ratios.--Nothing in 
        this title shall preempt State standards that the Secretary 
        determines to be at least equivalent to Federal requirements 
        for a staffing plan established under this title. Minimum 
        direct care registered nurse-to-patient ratios established 
        under this subsection shall not preempt State requirements that 
        the Secretary determines are at least equivalent to Federal 
        requirements for a staffing plan established under this title.
            ``(6) Exemption in emergencies.--The requirements 
        established under this subsection shall not apply during a 
        state of emergency if a hospital is requested or expected to 
        provide an exceptional level of emergency or other medical 
        services. The Secretary shall issue guidance to hospitals that 
        describes situations that constitute a state of emergency for 
        purposes of the exemption under this paragraph.
    ``(c) Development and Reevaluation of Staffing Plan.--
            ``(1) Considerations in development of plan.--In developing 
        the staffing plan, a hospital shall provide for direct care 
        registered nurse-to-patient ratios above the minimum direct 
        care registered nurse-to-patient ratios required under 
        subsection (b) if appropriate based upon consideration of the 
        following factors:
                    ``(A) The number of patients and acuity level of 
                patients as determined by the application of an acuity 
                system (as defined in section 3406(1)), on a shift-by-
                shift basis.
                    ``(B) The anticipated admissions, discharges, and 
                transfers of patients during each shift that impacts 
                direct patient care.
                    ``(C) Specialized experience required of direct 
                care registered nurses on a particular unit.
                    ``(D) Staffing levels and services provided by 
                licensed vocational or practical nurses, licensed 
                psychiatric technicians, certified nurse assistants, or 
                other ancillary staff in meeting direct patient care 
                needs not required by a direct care registered nurse.
                    ``(E) The level of technology available that 
                affects the delivery of direct patient care.
                    ``(F) The level of familiarity with hospital 
                practices, policies, and procedures by temporary agency 
                direct care registered nurses used during a shift.
                    ``(G) Obstacles to efficiency in the delivery of 
                patient care presented by physical layout.
            ``(2) Documentation of staffing.--A hospital shall specify 
        the system used to document actual staffing in each unit for 
        each shift.
            ``(3) Annual reevaluation of plan and acuity system.--
                    ``(A) In general.--A hospital shall annually 
                evaluate--
                            ``(i) its staffing plan in each unit in 
                        relation to actual patient care requirements; 
                        and
                            ``(ii) the accuracy of its acuity system.
                    ``(B) Update.--A hospital shall update its staffing 
                plan and acuity system to the extent appropriate based 
                on such evaluation.
            ``(4) Transparency.--
                    ``(A) In general.--Any acuity-based patient 
                classification system adopted by a hospital under this 
                section shall be transparent in all respects, including 
                disclosure of detailed documentation of the methodology 
                used to predict nursing staffing, identifying each 
                factor, assumption, and value used in applying such 
                methodology.
                    ``(B) Public availability.--The Secretary shall 
                establish procedures to provide that the documentation 
                submitted under subsection (e) is available for public 
                inspection in its entirety.
            ``(5) Registered nurse participation.--A staffing plan of a 
        hospital shall be developed and subsequent reevaluations shall 
        be conducted under this subsection on the basis of input from 
        direct care registered nurses at the hospital or, where such 
        nurses are represented through collective bargaining, from the 
        applicable recognized or certified collective bargaining 
        representative of such nurses. Nothing in this title shall be 
        construed to permit conduct prohibited under the National Labor 
        Relations Act or under the Federal Labor Relations Act.
    ``(d) Acuity Tool.--
            ``(1) In general.--Not later than 2 years after the date of 
        enactment of this title, the Secretary shall develop a process 
        to establish a national acuity tool that provides a transparent 
        method for establishing nurse staffing requirements that exceed 
        the minimum hospital unit direct care registered nurse-to-
        patient ratios required under subsection (b).
            ``(2) Implementation.--Each hospital unit shall adopt and 
        implement the national acuity tool described in paragraph (1), 
        and provide staffing based on such tool. Any additional direct 
        care registered nursing staffing above the hospital unit direct 
        care registered nurse-to-patient ratios described in subsection 
        (b) shall be assigned in a manner determined by such national 
        acuity tool.
    ``(e) Submission of Plan to Secretary.--A hospital shall submit to 
the Secretary its staffing plan and any annual updates under subsection 
(c)(3)(B). A federally operated hospital may submit its staffing plan 
through the department or agency operating the hospital.

``SEC. 3402. POSTING, RECORDS, AND AUDITS.

    ``(a) Posting Requirements.--In each unit, a hospital shall post a 
uniform notice in a form specified by the Secretary in regulation 
that--
            ``(1) explains requirements imposed under section 3401;
            ``(2) includes actual direct care registered nurse-to-
        patient ratios during each shift; and
            ``(3) is visible, conspicuous, and accessible to staff, 
        patients, and the public.
    ``(b) Records.--
            ``(1) Maintenance of records.--Each hospital shall maintain 
        accurate records of actual direct care registered nurse-to-
        patient ratios in each unit for each shift for no less than 3 
        years. Such records shall include--
                    ``(A) the number of patients in each unit;
                    ``(B) the identity and duty hours of each direct 
                care registered nurse assigned to each patient in each 
                unit in each shift; and
                    ``(C) a copy of each notice posted under subsection 
                (a).
            ``(2) Availability of records.--Each hospital shall make 
        its records maintained under paragraph (1) available to--
                    ``(A) the Secretary;
                    ``(B) registered nurses and their collective 
                bargaining representatives (if any); and
                    ``(C) the public under regulations established by 
                the Secretary, or in the case of a federally operated 
                hospital, under section 552 of title 5, United States 
                Code (commonly known as the `Freedom of Information 
                Act').
    ``(c) Audits.--The Secretary shall conduct periodic audits to 
ensure--
            ``(1) implementation of the staffing plan in accordance 
        with this title; and
            ``(2) accuracy in records maintained under this section.

``SEC. 3403. MINIMUM DIRECT CARE LICENSED PRACTICAL NURSE STAFFING 
              REQUIREMENTS.

    ``(a) Establishment.--A hospital's staffing plan shall comply with 
minimum direct care licensed practical nurse staffing requirements that 
the Secretary establishes for units in hospitals. Such staffing 
requirements shall be established not later than 18 months after the 
date of the enactment of this title, and shall be based on the study 
conducted under subsection (b).
    ``(b) Study.--Not later than 1 year after the date of the enactment 
of this title, the Secretary, acting through the Director of the Agency 
for Healthcare Research and Quality, shall complete a study of licensed 
practical nurse staffing and its effects on patient care in hospitals. 
The Director may contract with a qualified entity or organization to 
carry out such study under this paragraph. The Director shall consult 
with licensed practical nurses and organizations representing licensed 
practical nurses regarding the design and conduct of the study.
    ``(c) Application of Registered Nurse Provisions to Licensed 
Practical Nurse Staffing Requirements.--Paragraphs (2), (3), (4)(A), 
and (5) of section 3401(b), section 3401(c), and section 3402 shall 
apply to the establishment and application of direct care licensed 
practical nurse staffing requirements under this section in the same 
manner that they apply to the establishment and application of direct 
care registered nurse-to-patient ratios under sections 3401 and 3402.
    ``(d) Effective Date.--The requirements of this section shall take 
effect as soon as practicable, as determined by the Secretary, but not 
later than 2 years after the date of the enactment of this title, or in 
the case of a hospital in a rural area (as defined in section 
1886(d)(2)(D) of the Social Security Act), not later than 4 years after 
the date of the enactment of this title.

``SEC. 3404. ADJUSTMENT IN REIMBURSEMENT.

    ``(a) Medicare Reimbursement.--The Secretary shall adjust payments 
made to hospitals (other than federally operated hospitals) under title 
XVIII of the Social Security Act in an amount equal to the net amount 
of additional costs incurred in providing services to Medicare 
beneficiaries that are attributable to compliance with requirements 
imposed under sections 3401 through 3403. The amount of such payment 
adjustments shall take into account recommendations contained in the 
report submitted by the Medicare Payment Advisory Commission under 
subsection (c).
    ``(b) Authorization of Appropriation for Federally Operated 
Hospitals.--There are authorized to be appropriated such additional 
sums as are required for federally operated hospitals to comply with 
the additional requirements established under sections 3401 through 
3403.
    ``(c) Medpac Report.--Not later than 2 years after the date of the 
enactment of this title, the Medicare Payment Advisory Commission 
(established under section 1805 of the Social Security Act) shall 
submit to Congress and the Secretary a report estimating total costs 
and savings attributable to compliance with requirements imposed under 
sections 3401 through 3403. Such report shall include recommendations 
on the need, if any, to adjust reimbursement for Medicare payments 
under subsection (a).

``SEC. 3405. WHISTLEBLOWER AND PATIENT PROTECTIONS.

    ``(a) Objection to or Refusal of Assignment.--A nurse may object 
to, or refuse to participate in, any activity, policy, practice, 
assignment or task if in good faith--
            ``(1) the nurse reasonably believes it to be in violation 
        of section 3401 or 3403; or
            ``(2) the nurse is not prepared by education, training, or 
        experience to fulfill the assignment without compromising the 
        safety of any patient or jeopardizing the license of the nurse.
    ``(b) Retaliation for Objection to or Refusal of Assignment 
Barred.--
            ``(1) No discharge, discrimination, or retaliation.--No 
        hospital shall discharge, retaliate, discriminate, or otherwise 
        take adverse action in any manner with respect to any aspect of 
        a nurse's employment (as defined in section 3407(4)), including 
        discharge, promotion, compensation, or terms, conditions, or 
        privileges of employment, based on the nurse's refusal of a 
        work assignment under subsection (a).
            ``(2) No filing of complaint.--No hospital shall file a 
        complaint or a report against a nurse with a State professional 
        disciplinary agency because of the nurse's refusal of a work 
        assignment under subsection (a).
    ``(c) Cause of Action.--Any nurse who has been discharged, 
discriminated against, or retaliated against in violation of subsection 
(b)(1) or against whom a complaint or report has been filed in 
violation of subsection (b)(2) may (without regard to whether a 
complaint has been filed under subsection (d) of this section or 
subsection (b) of section 3406) bring a cause of action in a United 
States district court. A nurse who prevails on the cause of action 
shall be entitled to one or more of the following:
            ``(1) Reinstatement.
            ``(2) Reimbursement of lost wages, compensation, and 
        benefits.
            ``(3) Attorneys' fees.
            ``(4) Court costs.
            ``(5) Other damages.
    ``(d) Complaint to Secretary.--A nurse, patient, or other 
individual may file a complaint with the Secretary against a hospital 
that violates the provisions of this title. For any complaint filed, 
the Secretary shall--
            ``(1) receive and investigate the complaint;
            ``(2) determine whether a violation of this title as 
        alleged in the complaint has occurred; and
            ``(3) if such a violation has occurred, issue an order that 
        the complaining nurse or individual shall not suffer any 
        discharge, retaliation, discrimination, or other adverse action 
        prohibited by subsection (b) or subsection (f).
    ``(e) Toll-Free Telephone Number.--
            ``(1) In general.--The Secretary shall provide for the 
        establishment of a toll-free telephone hotline to provide 
        information regarding the requirements under sections 3401 
        through 3403 and to receive reports of violations of such 
        section.
            ``(2) Notice to patients.--A hospital shall provide each 
        patient admitted to the hospital for inpatient care with the 
        hotline described in paragraph (1), and shall give notice to 
        each patient that such hotline may be used to report inadequate 
        staffing or care.
    ``(f) Protection for Reporting.--
            ``(1) Prohibition on retaliation or discrimination.--A 
        hospital shall not discriminate or retaliate in any manner 
        against any patient, employee, or contract employee of the 
        hospital, or any other individual, on the basis that such 
        individual, in good faith, individually or in conjunction with 
        another person or persons, has presented a grievance or 
        complaint, or has initiated or cooperated in any investigation 
        or proceeding of any governmental entity, regulatory agency, or 
        private accreditation body, made a civil claim or demand, or 
        filed an action relating to the care, services, or conditions 
        of the hospital or of any affiliated or related facilities.
            ``(2) Good fath defined.--For purposes of this subsection, 
        an individual shall be deemed to be acting in good faith if the 
        individual reasonably believes--
                    ``(A) the information reported or disclosed is 
                true; and
                    ``(B) a violation of this title has occurred or may 
                occur.
    ``(g) Prohibition on Interference With Rights.--
            ``(1) Exercise of rights.--It shall be unlawful for any 
        hospital to--
                    ``(A) interfere with, restrain, or deny the 
                exercise, or attempt to exercise, by any person of any 
                right provided or protected under this title; or
                    ``(B) coerce or intimidate any person regarding the 
                exercise or attempt to exercise such right.
            ``(2) Opposition to unlawful policies or practices.--It 
        shall be unlawful for any hospital to discriminate or retaliate 
        against any person for opposing any hospital policy, practice, 
        or actions which are alleged to violate, breach, or fail to 
        comply with any provision of this title.
            ``(3) Prohibition on interference with protected 
        communications.--A hospital (or an individual representing a 
        hospital) shall not make, adopt, or enforce any rule, 
        regulation, policy, or practice which in any manner directly or 
        indirectly prohibits, impedes, or discourages a direct care 
        nurse from, or intimidates, coerces, or induces a direct care 
        nurse regarding, engaging in free speech activities or 
        disclosing information as provided under this title.
            ``(4) Prohibition on interference with collective action.--
        A hospital (or an individual representing a hospital) shall not 
        in any way interfere with the rights of nurses to organize, 
        bargain collectively, and engage in concerted activity under 
        section 7 of the National Labor Relations Act (29 U.S.C. 157).
    ``(h) Notice.--A hospital shall post in an appropriate location in 
each unit a conspicuous notice in a form specified by the Secretary 
that--
            ``(1) explains the rights of nurses, patients, and other 
        individuals under this section;
            ``(2) includes a statement that a nurse, patient, or other 
        individual may file a complaint with the Secretary against a 
        hospital that violates the provisions of this title; and
            ``(3) provides instructions on how to file such a 
        complaint.
    ``(i) Effective Date.--
            ``(1) Refusal; retaliation; cause of action.--
                    ``(A) In general.--Subsections (a) through (c) 
                shall apply to objections and refusals occurring on or 
                after the effective date of the provision of this title 
                to which the objection or refusal relates.
                    ``(B) Exception.--Subsection (a)(2) shall not apply 
                to objections or refusals in any hospital before the 
                requirements of section 3401(a) or 3403(a), as 
                applicable, apply to that hospital.
            ``(2) Protections for reporting.--Subsection (f)(1) shall 
        apply to actions occurring on or after the effective date of 
        the provision to which the violation relates, except that such 
        subsection shall apply to initiation, cooperation, or 
        participation in an investigation or proceeding on or after the 
        date of enactment of this title.
            ``(3) Notice.--Subsection (h) shall take effect 18 months 
        after the date of enactment of this title.

``SEC. 3406. ENFORCEMENT.

    ``(a) In General.--The Secretary shall enforce the requirements and 
prohibitions of this title in accordance with this section.
    ``(b) Procedures for Receiving and Investigating Complaints.--The 
Secretary shall establish procedures under which--
            ``(1) any person may file a complaint alleging that a 
        hospital has violated a requirement or a prohibition of this 
        title; and
            ``(2) such complaints shall be investigated by the 
        Secretary.
    ``(c) Remedies.--If the Secretary determines that a hospital has 
violated a requirement of this title, the Secretary--
            ``(1) shall require the facility to establish a corrective 
        action plan to prevent the recurrence of such violation; and
            ``(2) may impose civil money penalties, as described in 
        subsection (d).
    ``(d) Civil Penalties.--
            ``(1) In general.--In addition to any other penalties 
        prescribed by law, the Secretary may impose civil penalties as 
        follows:
                    ``(A) Hospital liability.--The Secretary may impose 
                on a hospital found to be in violation of this title, a 
                civil money penalty of not more than $25,000 for each 
                knowing violation of a requirement of this title, 
                except that the Secretary shall impose a civil money 
                penalty of more than $25,000 for each such violation in 
                the case of a participating hospital that the Secretary 
                determines has a pattern or practice of such violations 
                (with the amount of such additional penalties being 
                determined in accordance with a schedule or methodology 
                specified in regulations).
                    ``(B) Individual liability.--The Secretary may 
                impose on an individual who--
                            ``(i) is employed by a hospital found by 
                        the Secretary to have violated a requirement of 
                        this title; and
                            ``(ii) willfully violates this title,
                a civil money penalty of not more than $20,000 for each 
                such violation.
            ``(2) Procedures.--The provisions of section 1128A of the 
        Social Security Act (other than subsections (a) and (b)) shall 
        apply to a civil money penalty under this paragraph in the same 
        manner as such provisions apply to a penalty or proceeding 
        under such section 1128A.
    ``(e) Public Notice of Violations.--
            ``(1) Internet website.--The Secretary shall publish on the 
        Internet website of the Department of Health and Human Services 
        the names of participating hospitals on which civil money 
        penalties have been imposed under this subsection, the 
        violation for which such penalty was imposed, and such 
        additional information as the Secretary determines appropriate.
            ``(2) Change of ownership.--With respect to a participating 
        hospital that had a change of ownership, as determined by the 
        Secretary, penalties imposed on the hospital while under 
        previous ownership shall no longer be published by the 
        Secretary of such Internet website after the 1-year period 
        beginning on the date of change of ownership.
    ``(f) Offset.--Funds collected by the Secretary under this section 
shall be used to offset the costs of enforcing this title.

``SEC. 3407. DEFINITIONS.

    ``For purposes of this title:
            ``(1) Acuity system.--The term `acuity system' means an 
        established measurement tool that--
                    ``(A) predicts nursing care requirements for 
                individual patients based on severity of patient 
                illness, need for specialized equipment and technology, 
                intensity of nursing interventions required, and the 
                complexity of clinical nursing judgment needed to 
                design, implement, and evaluate the patient's nursing 
                care plan;
                    ``(B) details the amount of nursing care needed, 
                both in number of nurses and in skill mix of nursing 
                personnel required, on a daily basis, for each patient 
                in a nursing department or unit;
                    ``(C) takes into consideration the patient care 
                services provided not only by registered nurses but 
                also by direct care licensed practical nurses and other 
                health care personnel; and
                    ``(D) is stated in terms that can be readily used 
                and understood by nurses.
            ``(2) Direct care licensed practical nurse.--The term 
        `direct care licensed practical nurse' means an individual who 
        has been granted a license by at least 1 State to practice as a 
        licensed practical nurse or a licensed vocational nurse and who 
        provides bedside care for 1 or more patients.
            ``(3) Direct care registered nurse.--The term `direct care 
        registered nurse' means an individual who has been granted a 
        license by at least 1 State to practice as a registered nurse 
        and who provides bedside care for 1 or more patients.
            ``(4) Employment.--The term `employment' includes the 
        provision of services under a contract or other arrangement.
            ``(5) Hospital.--The term `hospital' has the meaning given 
        that term in section 1861(e) of the Social Security Act, and 
        includes a hospital that is operated by the Department of 
        Veterans Affairs, the Department of Defense, the Indian Health 
        Services Program, or any other department or agency of the 
        United States.
            ``(6) Nurse.--The term `nurse' means any direct care 
        registered nurse or direct care licensed practical nurse (as 
        the case may be), regardless of whether or not the nurse is an 
        employee.
            ``(7) Staffing plan.--The term `staffing plan' means a 
        staffing plan required under section 3401.
            ``(8) State of emergency.--The term `state of emergency'--
                    ``(A) means a state of emergency that is an 
                unpredictable or unavoidable occurrence at an 
                unscheduled or unpredictable interval, relating to 
                health care delivery and requiring immediate medical 
                interventions and care; and
                    ``(B) does not include a state emergency that 
                results from a labor dispute in the health care 
                industry or consistent understaffing.

``SEC. 3408. RULE OF CONSTRUCTION.

    ``Nothing in this title shall be construed to authorize disclosure 
of private and confidential patient information, except in the case 
where such disclosure is otherwise required by law, compelled by proper 
legal process, consented to by the patient, provided in confidence to 
regulatory or accreditation agencies or other government entities for 
investigatory purposes, or provided pursuant to formal or informal 
complaints of unlawful or improper practices for purposes of achieving 
corrective and remedial action.''.
    (b) Recommendations to Congress.--Not later than 1 year after the 
date of enactment of this Act, the Secretary of Health and Human 
Services shall submit to Congress a report containing recommendations 
for ensuring that sufficient numbers of nurses are available to meet 
the requirements imposed by title XXXIV of the Public Health Service 
Act, as added by subsection (a).
    (c) Report by HRSA.--
            (1) In general.--Not later than 2 years after the date of 
        enactment of this Act, the Administrator of the Health 
        Resources and Services Administration, in consultation with the 
        National Health Care Workforce Commission, shall submit to 
        Congress a report regarding the relationship between nurse 
        staffing levels and nurse retention in hospitals.
            (2) Updated report.--Not later than 5 years after the date 
        of enactment of this Act, the Administrator of the Health 
        Resources and Services Administration, in consultation with the 
        National Health Care Workforce Commission, shall submit to 
        Congress an update of the report submitted under paragraph (1).

SEC. 3. ENFORCEMENT OF REQUIREMENTS THROUGH FEDERAL PROGRAMS.

    (a) Medicare Program.--Section 1866(a)(1) of the Social Security 
Act (42 U.S.C. 1395cc(a)(1)) is amended--
            (1) by striking ``and'' at the end of subparagraph (V);
            (2) by striking the period at the end of the subparagraph 
        (W) added by section 3005(1)(C) of Public Law 111-148 and 
        inserting a semicolon;
            (3) by striking the period at the end of the subparagraph 
        (W) added by section 6406(b)(3) of Public Law 111-148 and 
        inserting ``; and''; and
            (4) by inserting after the subparagraph (W) added by such 
        section 6406(b)(3) the following:
                    ``(W) in the case of a hospital, to comply with the 
                provisions of title XXXIV of the Public Health Service 
                Act.''.
    (b) Medicaid Program.--Section 1902(a) of the Social Security Act 
(42 U.S.C. 1396(a)) is amended--
            (1) by striking ``and'' at the end of paragraph (82)(C);
            (2) by striking the period at the end of paragraph (83) and 
        inserting ``; and''; and
            (3) by inserting after paragraph (83) the following new 
        paragraph:
            ``(84) provide that any hospital that receives a payment 
        under such plan comply with the provisions of title XXXIV of 
        the Public Health Service Act (relating to minimum direct care 
        registered nurse staffing requirements).''.
    (c) Health Benefits Program of the Department of Veterans 
Affairs.--Section 8110(a) of title 38, United States Code, is amended 
by adding at the end the following new paragraphs:
    ``(7) In the case of a Department medical facility that is a 
hospital, the hospital shall comply with the provisions of title XXXIV 
of the Public Health Service Act.
    ``(8) Nothing either in chapter 74 of this title or in section 7106 
of title 5 shall preclude enforcement of the provisions of title XXXIV 
of the Public Health Service Act with respect to a Department hospital 
through grievance procedures negotiated in accordance with chapter 71 
of title 5.''.
    (d) Health Benefits Program of the Department of Defense.--
            (1) In general.--Chapter 55 of title 10, United States 
        Code, is amended by adding at the end the following new 
        section:
``Sec. 1110c. Staffing requirements
    ``In the case of a facility of the uniformed services that is a 
hospital, the hospital shall comply with the provisions of title XXXIV 
of the Public Health Service Act.''.
            (2) Clerical amendment.--The table of sections at the 
        beginning of such chapter is amended by inserting after the 
        item relating to section 1110b the following new item:

``1110c. Staffing requirements''.
    (e) Indian Health Services Program.--Title VIII of the Indian 
Health Care Improvement Act (25 U.S.C. 1671 et seq.) is amended by 
adding at the end the following new section:

``SEC. 833. STAFFING REQUIREMENTS.

    ``All hospitals of the Service shall comply with the provisions of 
title XXXIV of the Public Health Service Act (relating to minimum 
direct care registered nurse staffing requirements).''.
    (f) Federal Labor-Management Relations.--
            (1) In general.--Section 7106 of title 5, United States 
        Code, is amended by adding at the end the following:
    ``(c) Nothing in this section shall preclude enforcement of the 
provisions of title XXXIV of the Public Health Service Act through 
grievance procedures negotiated in accordance with section 7121.''.
            (2) Conforming amendment.--Section 7106(a) of title 5, 
        United States Code, is amended by striking ``Subject to 
        subsection (b) of this title,'' and inserting ``Subject to 
        subsections (b) and (c),''.
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