II 

115TH CONGRESS 

2D SESSION S. 2446 

To amend title XVIII of the Social Security Act to provide for patient 

protection by establishing safe nurse staffing levels at certain Medicare 

providers, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

FEBRUARY 15, 2018 

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

to the Committee on Finance 

A BILL 

To amend title XVIII of the Social Security Act to provide 

for patient protection by establishing safe nurse staffing 

levels at certain Medicare providers, 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 ‘‘Safe Staffing for 

5 Nurse and Patient Safety Act of 2018’’. 

6 SEC. 2. FINDINGS. 

7 Congress makes the following findings: 


rfrederick on DSKBCBPHB2PROD with BILLS
2 

•S 2446 IS

1 (1) The overwhelming weight of academic re2 search continues to demonstrate patient that safety, 

3 prevention of medication errors, failure to rescue sit4 uations, patient deterioration, patient death, and 

5 nurse burnout are all proportionate to the number of 

6 nurses staffed in a hospital. Therefore, higher staff7 ing levels by experienced registered nurses are asso8 ciated with lower rates of negative patient outcomes 

9 and costs. 

10 (2) Proper nurse staffing decreases the rate of 

11 patients’ hospital readmissions. Medicare does not 

12 pay hospitals for patients who are readmitted for the 

13 same condition within 30 days. In 2013, 17.5 per14 cent of Medicare beneficiaries were readmitted to a 

15 hospital within 30 days following discharge. These 

16 readmissions cost Medicare an estimated $26 billion 

17 per year. The research indicates, however, that prop18 er nurse staffing reduces such readmissions and 

19 pays for itself over the long term. 

20 (3) The 2015 National Healthcare Retention 

21 and RN Staffing Report revealed that nurse turn22 over costs the average U.S. hospital nearly $5 mil23 lion dollars every year. Appropriate nurse staffing 

24 reduces nurse burnout and turnover, saving hos25 pitals money. 


rfrederick on DSKBCBPHB2PROD with BILLS
3 

•S 2446 IS

1 (4) Proper nurse staffing helps prevent medica2 tion errors and nurse burnout through decreasing 

3 healthcare worker fatigue. Healthcare worker fatigue 

4 is a major patient safety hazard. The academic lit5 erature indicates that appropriate staffing policies 

6 and practices are an effective strategy to reducing 

7 such fatigue and protecting patients. 

8 (5) Research shows that optimal nurse staffing 

9 and skill mix improves patient satisfaction, and re10 sults in savings to hospitals through reductions in 

11 negative, adverse patient events. Improved patient 

12 satisfaction due to appropriate nurse staffing is re13 flected in hospitals’ patient satisfaction survey re14 sults, which are publicly reported, and are a key 

15 measure for value-based payment programs. 

16 (6) Research indicates that patients who receive 

17 care during periods of sub-optimal nurse staffing ex18 perience increased rates of medication errors, in19 creased rates of death, increased rates of failure-to20 rescue, and worse outcomes. 

21 (7) As a payor for inpatient and outpatient hos22 pital services furnished to Medicare beneficiaries, the 

23 Federal Government has a compelling interest in 

24 promoting the safety of hospitalized patients by re25 quiring any hospital participating in the Medicare 


rfrederick on DSKBCBPHB2PROD with BILLS
4 

•S 2446 IS

1 program to establish appropriate registered nurse 

2 staffing levels. 

3 SEC. 3. ESTABLISHMENT OF SAFE NURSE STAFFING LEV4 ELS BY MEDICARE PARTICIPATING HOS5 PITALS. 

6 (a) REQUIREMENT OF MEDICARE PROVIDER AGREE7 MENT.—Section 1866(a)(1) of the Social Security Act (42 

8 U.S.C. 1395cc(a)(1)) is amended— 

9 (1) by striking ‘‘and’’ at the end of subpara10 graph (X); 

11 (2) by striking the period at the end of sub12 paragraph (Y) and inserting ‘‘, and’’; and 

13 (3) by inserting after subparagraph (Y) the fol14 lowing new subparagraph: 

15 ‘‘(Z) in the case of a hospital (as defined in sec16 tion 1861(e)), to meet the requirements of section 

17 1899C.’’. 

18 (b) REQUIREMENTS.—Title XVIII of the Social Secu19 rity Act (42 U.S.C. 1395 et seq.) is amended by adding 

20 at the end the following new section: 

21 ‘‘NURSE STAFFING REQUIREMENTS FOR MEDICARE

22 PARTICIPATING HOSPITALS

23 ‘‘SEC. 1899C. (a) IMPLEMENTATION OF NURSE

24 STAFFING PLAN.— 

25 ‘‘(1) IN GENERAL.—Subject to paragraph (3), 

26 each participating hospital shall implement a hosVerDate Sep 11 2014 23:30 Feb 23, 2018 Jkt 079200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S2446.IS S2446

rfrederick on DSKBCBPHB2PROD with BILLS
5 

•S 2446 IS

1 pital-wide staffing plan for nursing services fur2 nished in the hospital. 

3 ‘‘(2) REQUIREMENT FOR DEVELOPMENT OF

4 STAFFING PLAN BY HOSPITAL NURSE STAFFING

5 COMMITTEE.—The hospital-wide staffing plan for 

6 nursing services implemented by a hospital pursuant 

7 to paragraph (1)— 

8 ‘‘(A) shall be developed by the hospital 

9 nurse staffing committee established under sub10 section (b); and 

11 ‘‘(B) shall require that an appropriate 

12 number of registered nurses provide direct pa13 tient care in each unit and on each shift of the 

14 hospital to ensure staffing levels that— 

15 ‘‘(i) address the unique characteristics 

16 of the patients and hospital units; and 

17 ‘‘(ii) result in the delivery of safe, 

18 quality patient care, consistent with the re19 quirements under subsection (c). 

20 ‘‘(b) HOSPITAL NURSE STAFFING COMMITTEE.— 

21 ‘‘(1) ESTABLISHMENT.—Each participating 

22 hospital shall establish a hospital nurse staffing 

23 committee (in this section referred to as the ‘Com24 mittee’). 


rfrederick on DSKBCBPHB2PROD with BILLS
6 

•S 2446 IS

1 ‘‘(2) COMPOSITION.—A Committee established 

2 pursuant to this subsection shall be composed of 

3 members as follows: 

4 ‘‘(A) MINIMUM 55 PERCENT NURSE PAR5 TICIPATION.—Not less than 55 percent of the 

6 members of the Committee shall be registered 

7 nurses who provide direct patient care but who 

8 are neither hospital nurse managers nor part of 

9 the hospital administration staff. 

10 ‘‘(B) INCLUSION OF HOSPITAL NURSE

11 MANAGERS.—The Committee shall include 

12 members who are hospital nurse managers. 

13 ‘‘(C) INCLUSION OF NURSES FROM SPE14 CIALTY UNITS.—The members of the Com15 mittee shall include at least 1 registered nurse 

16 who provides direct care from each nurse spe17 cialty or unit of the hospital (each such spe18 cialty or unit as determined by the hospital). 

19 ‘‘(D) OTHER HOSPITAL PERSONNEL.—The 

20 Committee shall include such other personnel of 

21 the hospital as the hospital determines to be ap22 propriate. 

23 ‘‘(3) DUTIES.— 

24 ‘‘(A) DEVELOPMENT OF STAFFING

25 PLAN.—The Committee shall develop a hospitalVerDate Sep 11 2014 23:30 Feb 23, 2018 Jkt 079200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S2446.IS S2446

rfrederick on DSKBCBPHB2PROD with BILLS
7 

•S 2446 IS

1 wide staffing plan for nursing services furnished 

2 in the hospital consistent with the requirements 

3 under subsection (c). 

4 ‘‘(B) REVIEW AND MODIFICATION OF

5 STAFFING PLAN.—The Committee shall— 

6 ‘‘(i) conduct regular, ongoing moni7 toring of the implementation of the hos8 pital-wide staffing plan for nursing services 

9 furnished in the hospital; 

10 ‘‘(ii) carry out evaluations of the hos11 pital-wide staffing plan for nursing services 

12 at least annually; and 

13 ‘‘(iii) make such modifications to the 

14 hospital-wide staffing plan for nursing 

15 services as may be appropriate. 

16 ‘‘(C) ADDITIONAL DUTIES.—The Com17 mittee shall— 

18 ‘‘(i) develop policies and procedures 

19 for overtime requirements of registered 

20 nurses providing direct patient care and 

21 for appropriate time and manner of relief 

22 of such registered nurses during routine 

23 absences; and 


rfrederick on DSKBCBPHB2PROD with BILLS
8 

•S 2446 IS

1 ‘‘(ii) carry out such additional duties 

2 as the Committee determines to be appro3 priate. 

4 ‘‘(c) STAFFING PLAN REQUIREMENTS.— 

5 ‘‘(1) PLAN REQUIREMENTS.—Subject to para6 graph (2), a hospital-wide staffing plan for nursing 

7 services developed and implemented under this sec8 tion shall— 

9 ‘‘(A) be based upon input from the reg10 istered nurse staff of the hospital who provide 

11 direct patient care or their exclusive representa12 tives, as well as the chief nurse executive; 

13 ‘‘(B) be based upon the number of patients 

14 and the level and variability of intensity of care 

15 to be provided to those patients, with appro16 priate consideration given to admissions, dis17 charges, and transfers during each shift; 

18 ‘‘(C) take into account contextual issues 

19 affecting nurse staffing and the delivery of care, 

20 including architecture and geography of the en21 vironment and available technology; 

22 ‘‘(D) take into account the level of edu23 cation, training, and experience of those reg24 istered nurses providing direct patient care; 


rfrederick on DSKBCBPHB2PROD with BILLS
9 

•S 2446 IS

1 ‘‘(E) take into account the staffing levels 

2 and services provided by other health care per3 sonnel associated with nursing care, such as 

4 certified nurse assistants, licensed vocational 

5 nurses, licensed psychiatric technicians, nursing 

6 assistants, aides, and orderlies; 

7 ‘‘(F) take into account staffing levels rec8 ommended by specialty nursing organizations; 

9 ‘‘(G) establish upwardly adjustable min10 imum ratios of direct care registered nurses to 

11 patients for each unit and for each shift of the 

12 hospital, based upon an assessment by reg13 istered nurses of the level and variability of in14 tensity of care required by patients under exist15 ing conditions; 

16 ‘‘(H) take into account unit and facility 

17 level staffing, quality and patient outcome data, 

18 and national comparisons, as available; 

19 ‘‘(I) ensure that a registered nurse shall 

20 not be assigned to work in a particular unit of 

21 the hospital without first having established the 

22 ability to provide professional care in such unit; 

23 and 

24 ‘‘(J) provide for exemptions from some or 

25 all requirements of the hospital-wide staffing 


rfrederick on DSKBCBPHB2PROD with BILLS
10 

•S 2446 IS

1 plan for nursing services during a declared 

2 state of emergency (as defined in subsection 

3 (l)(1)) if the hospital is requested or expected 

4 to provide an exceptional level of emergency or 

5 other medical services. 

6 ‘‘(2) LIMITATION.—A hospital-wide staffing 

7 plan for nursing services developed and implemented 

8 under this section— 

9 ‘‘(A) shall not preempt any registered10 nurse staffing levels established under State law 

11 or regulation; and 

12 ‘‘(B) may not utilize any minimum number 

13 of registered nurses established under para14 graph (1)(G) as an upper limit on the nurse 

15 staffing of the hospital to which such minimum 

16 number applies. 

17 ‘‘(d) REPORTING AND RELEASE TO PUBLIC OF CER18 TAIN STAFFING INFORMATION.— 

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

20 participating hospital shall— 

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

22 visible place, a document that specifies in a uni23 form manner (as prescribed by the Secretary) 

24 the current number of licensed and unlicensed 

25 nursing staff directly responsible for patient 


rfrederick on DSKBCBPHB2PROD with BILLS
11 

•S 2446 IS

1 care in each unit of the hospital, identifying 

2 specifically the number of registered nurses; 

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

4 public— 

5 ‘‘(i) the nursing staff information de6 scribed in subparagraph (A); 

7 ‘‘(ii) a detailed written description of 

8 the hospital-wide staffing plan imple9 mented by the hospital pursuant to sub10 section (a); and 

11 ‘‘(iii) not later than 90 days after the 

12 date on which an evaluation is carried out 

13 by the Committee under subsection 

14 (b)(3)(B)(ii), a copy of such evaluation; 

15 and 

16 ‘‘(C) not less frequently than quarterly, 

17 submit to the Secretary in a uniform manner 

18 (as prescribed by the Secretary) the nursing 

19 staff information described in subparagraph (A) 

20 through electronic data submission. 

21 ‘‘(2) SECRETARIAL RESPONSIBILITIES.—The 

22 Secretary shall— 

23 ‘‘(A) make the information submitted pur24 suant to paragraph (1)(C) publicly available in 

25 a comprehensible format (as described in subVerDate Sep 11 2014 23:30 Feb 23, 2018 Jkt 079200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S2446.IS S2446

rfrederick on DSKBCBPHB2PROD with BILLS
12 

•S 2446 IS

1 section (e)(2)(D)(ii)), including by publication 

2 on the Hospital Compare Internet Web site of 

3 the Department of Health and Human Services; 

4 and 

5 ‘‘(B) provide for the auditing of such infor6 mation for accuracy as a part of the process of 

7 determining whether the participating hospital 

8 is in compliance with the conditions of its 

9 agreement with the Secretary under section 

10 1866, including under subsection (a)(1)(Y) of 

11 such section. 

12 ‘‘(e) RECORDKEEPING; COLLECTION AND REPORT13 ING OF QUALITY DATA; EVALUATION.— 

14 ‘‘(1) RECORDKEEPING.—Each participating 

15 hospital shall maintain for a period of at least 3 

16 years (or, if longer, until the conclusion of any pend17 ing enforcement activities) such records as the Sec18 retary deems necessary to determine whether the 

19 hospital has implemented a hospital-wide staffing 

20 plan for nursing services pursuant to subsection (a). 

21 ‘‘(2) COLLECTION AND REPORTING OF QUALITY

22 DATA ON NURSING SERVICES.— 

23 ‘‘(A) IN GENERAL.—The Secretary shall 

24 require the collection, aggregation, mainte25 nance, and reporting of quality data relating to 


rfrederick on DSKBCBPHB2PROD with BILLS
13 

•S 2446 IS

1 nursing services furnished by each participating 

2 hospital. 

3 ‘‘(B) USE OF ENDORSED MEASURES.—In 

4 carrying out this paragraph, the Secretary shall 

5 use only quality measures for nursing-sensitive 

6 care that are endorsed by the consensus-based 

7 entity with a contract under section 1890(a). 

8 ‘‘(C) USE OF QUALIFIED THIRD-PARTY EN9 TITIES FOR COLLECTION AND SUBMISSION OF

10 DATA.— 

11 ‘‘(i) IN GENERAL.—A participating 

12 hospital may enter into agreements with 

13 third-party entities that have demonstrated 

14 expertise in the collection and submission 

15 of quality data on nursing services to col16 lect, aggregate, maintain, and report the 

17 quality data of the hospital pursuant to 

18 subparagraph (A). 

19 ‘‘(ii) CONSTRUCTION.—Nothing in 

20 clause (i) shall be construed to excuse or 

21 exempt a participating hospital that has 

22 entered into an agreement described in 

23 such clause from compliance with require24 ments for quality data collection, aggregaVerDate Sep 11 2014 23:30 Feb 23, 2018 Jkt 079200 PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 E:\BILLS\S2446.IS S2446

rfrederick on DSKBCBPHB2PROD with BILLS
14 

•S 2446 IS

1 tion, maintenance, and reporting imposed 

2 under this paragraph. 

3 ‘‘(D) REPORTING OF QUALITY DATA.— 

4 ‘‘(i) PUBLICATION ON HOSPITAL COM5 PARE WEB SITE.—Subject to the suc6 ceeding provisions of this subparagraph, 

7 the Secretary shall make the data sub8 mitted pursuant to subparagraph (A) pub9 licly available, including by publication on 

10 the Hospital Compare Internet Web site of 

11 the Department of Health and Human 

12 Services. 

13 ‘‘(ii) COMPREHENSIBLE FORMAT.— 

14 Data made available to the public under 

15 clause (i) shall be presented in a clearly 

16 understandable format that permits con17 sumers of hospital services to make mean18 ingful comparisons among hospitals, in19 cluding concise explanations in plain 

20 English of how to interpret the data, of the 

21 difference in types of nursing staff, of the 

22 relationship between nurse staffing levels 

23 and quality of care, and of how nurse 

24 staffing may vary based on patient case 

25 mix. 


rfrederick on DSKBCBPHB2PROD with BILLS
15 

•S 2446 IS

1 ‘‘(iii) OPPORTUNITY TO CORRECT ER2 RORS.—The Secretary shall establish a 

3 process under which participating hospitals 

4 may review data submitted to the Sec5 retary pursuant to subparagraph (A) to 

6 correct errors, if any, contained in that 

7 data submission before making the data 

8 available to the public under clause (i). 

9 ‘‘(3) EVALUATION OF DATA.—The Secretary 

10 shall provide for the analysis of quality data col11 lected from participating hospitals under paragraph 

12 (2) in order to evaluate the effect of hospital-wide 

13 staffing plans for nursing services implemented pur14 suant to subsection (a) on— 

15 ‘‘(A) patient outcomes that are nursing 

16 sensitive (such as pressure ulcers, fall occur17 rence, falls resulting in injury, length of stay, 

18 and central line catheter infections); and 

19 ‘‘(B) nursing workforce safety and reten20 tion (including work-related injury, staff skill 

21 mix, nursing care hours per patient day, va22 cancy and voluntary turnover rates, overtime 

23 rates, use of temporary agency personnel, and 

24 nurse satisfaction). 


rfrederick on DSKBCBPHB2PROD with BILLS
16 

•S 2446 IS

1 ‘‘(f) REFUSAL OF ASSIGNMENT.—A nurse may refuse 

2 to accept an assignment as a nurse in a participating hos3 pital, or in a unit of a participating hospital, if— 

4 ‘‘(1) the assignment is in violation of the hos5 pital-wide staffing plan for nursing services imple6 mented pursuant to subsection (a); or 

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

8 training, or experience to fulfill the assignment with9 out compromising the safety of any patient or jeop10 ardizing the license of the nurse. 

11 ‘‘(g) ENFORCEMENT.— 

12 ‘‘(1) RESPONSIBILITY.—The Secretary shall en13 force the requirements and prohibitions of this sec14 tion in accordance with the succeeding provisions of 

15 this subsection. 

16 ‘‘(2) PROCEDURES FOR RECEIVING AND INVES17 TIGATING COMPLAINTS.—The Secretary shall estab18 lish procedures under which— 

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

20 a participating hospital has violated a require21 ment of or a prohibition under this section; and 

22 ‘‘(B) such complaints are investigated by 

23 the Secretary. 

24 ‘‘(3) REMEDIES.—Except as provided in para25 graph (5), if the Secretary determines that a particiVerDate Sep 11 2014 23:30 Feb 23, 2018 Jkt 079200 PO 00000 Frm 00016 Fmt 6652 Sfmt 6201 E:\BILLS\S2446.IS S2446

rfrederick on DSKBCBPHB2PROD with BILLS
17 

•S 2446 IS

1 pating hospital has violated a requirement of this 

2 section, the Secretary— 

3 ‘‘(A) shall require the hospital to establish 

4 a corrective action plan to prevent the recur5 rence of such violation; and 

6 ‘‘(B) may impose civil money penalties 

7 under paragraph (4). 

8 ‘‘(4) CIVIL MONEY PENALTIES.— 

9 ‘‘(A) IN GENERAL.—In addition to any 

10 other penalties prescribed by law, the Secretary 

11 may impose a civil money penalty of not more 

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

13 requirement of this section, except that the Sec14 retary shall impose a civil money penalty of 

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

16 the case of a participating hospital that the 

17 Secretary determines has a pattern or practice 

18 of such violations (with the amount of such ad19 ditional penalties being determined in accord20 ance with a schedule or methodology specified 

21 in regulations). 

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

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

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

25 this paragraph in the same manner as such 


rfrederick on DSKBCBPHB2PROD with BILLS
18 

•S 2446 IS

1 provisions apply to a penalty or proceeding 

2 under section 1128A. 

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

4 ‘‘(i) INTERNET WEB SITE.—The Sec5 retary shall publish on an appropriate 

6 Internet Web site of the Department of 

7 Health and Human Services the names of 

8 participating hospitals on which civil 

9 money penalties have been imposed under 

10 this section, the violation for which the 

11 penalty was imposed, and such additional 

12 information as the Secretary determines 

13 appropriate. 

14 ‘‘(ii) CHANGE OF OWNERSHIP.—With 

15 respect to a participating hospital that had 

16 a change in ownership, as determined by 

17 the Secretary, penalties imposed on the 

18 hospital while under previous ownership 

19 shall no longer be published by the Sec20 retary of such Internet Web site after the 

21 1-year period beginning on the date of the 

22 change in ownership. 

23 ‘‘(5) PENALTY FOR FAILURE TO COLLECT AND

24 REPORT QUALITY DATA ON NURSING SERVICES.— 


rfrederick on DSKBCBPHB2PROD with BILLS
19 

•S 2446 IS

1 ‘‘(A) IN GENERAL.—In the case of a par2 ticipating hospital that fails to comply with re3 quirements under subsection (e)(2) to collect, 

4 aggregate, maintain, and report quality data re5 lating to nursing services furnished by the hos6 pital, instead of the remedies described in para7 graph (3), the provisions of subparagraph (B) 

8 shall apply with respect to each such failure of 

9 the participating hospital. 

10 ‘‘(B) PENALTY.—In the case of a failure 

11 by a participating hospital to comply with the 

12 requirements under subsection (e)(2) for a year, 

13 each such failure shall be deemed to be a failure 

14 to submit data required under section 

15 1833(t)(17)(A), section 1886(b)(3)(B)(viii), 

16 section 1886(j)(7)(A), or section 

17 1886(m)(5)(A), as the case may be, with re18 spect to the participating hospital involved for 

19 that year. 

20 ‘‘(h) WHISTLEBLOWER PROTECTIONS.— 

21 ‘‘(1) PROHIBITION OF DISCRIMINATION AND

22 RETALIATION.—A participating hospital shall not 

23 discriminate or retaliate in any manner against any 

24 patient or employee of the hospital because that pa25 tient or employee, or any other person, has preVerDate Sep 11 2014 23:30 Feb 23, 2018 Jkt 079200 PO 00000 Frm 00019 Fmt 6652 Sfmt 6201 E:\BILLS\S2446.IS S2446

rfrederick on DSKBCBPHB2PROD with BILLS
20 

•S 2446 IS

1 sented a grievance or complaint, or has initiated or 

2 cooperated in any investigation or proceeding of any 

3 kind, relating to— 

4 ‘‘(A) the hospital-wide staffing plan for 

5 nursing services developed and implemented 

6 under this section; or 

7 ‘‘(B) any right, other requirement or pro8 hibition under this section, including a refusal 

9 to accept an assignment described in subsection 

10 (f). 

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

12 An employee of a participating hospital who has 

13 been discriminated or retaliated against in employ14 ment in violation of this subsection may initiate judi15 cial action in a United States district court and shall 

16 be entitled to reinstatement, reimbursement for lost 

17 wages, and work benefits caused by the unlawful 

18 acts of the employing hospital. Prevailing employees 

19 are entitled to reasonable attorney’s fees and costs 

20 associated with pursuing the case. 

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

22 patient who has been discriminated or retaliated 

23 against in violation of this subsection may initiate 

24 judicial action in a United States district court. A 

25 prevailing patient shall be entitled to liquidated 


rfrederick on DSKBCBPHB2PROD with BILLS
21 

•S 2446 IS

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

2 addition to any other damages under other applica3 ble statutes, regulations, or common law. Prevailing 

4 patients are entitled to reasonable attorney’s fees 

5 and costs associated with pursuing the case. 

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

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

8 years after the discrimination or retaliation with re9 spect to which the action is brought. 

10 ‘‘(5) TREATMENT OF ADVERSE EMPLOYMENT

11 ACTIONS.—For purposes of this subsection— 

12 ‘‘(A) an adverse employment action shall 

13 be treated as discrimination or retaliation; and 

14 ‘‘(B) the term ‘adverse employment action’ 

15 includes— 

16 ‘‘(i) the failure to promote an indi17 vidual or provide any other employment-re18 lated benefit for which the individual would 

19 otherwise be eligible; 

20 ‘‘(ii) an adverse evaluation or decision 

21 made in relation to accreditation, certifi22 cation, credentialing, or licensing of the in23 dividual; and 

24 ‘‘(iii) a personnel action that is ad25 verse to the individual concerned. 


rfrederick on DSKBCBPHB2PROD with BILLS
22 

•S 2446 IS

1 ‘‘(i) RELATIONSHIP TO STATE LAWS.—Nothing in 

2 this section shall be construed as exempting or relieving 

3 any person from any liability, duty, penalty, or punish4 ment provided by the law of any State or political subdivi5 sion of a State, other than any such law which purports 

6 to require or permit any action prohibited under this title. 

7 ‘‘(j) RELATIONSHIP TO CONDUCT PROHIBITED

8 UNDER THE NATIONAL LABOR RELATIONS ACT OR

9 OTHER COLLECTIVE BARGAINING LAWS.—Nothing in 

10 this section shall be construed as— 

11 ‘‘(1) permitting conduct prohibited under the 

12 National Labor Relations Act or under any other 

13 Federal, State, or local collective bargaining law; or 

14 ‘‘(2) preempting, limiting, or modifying a collec15 tive bargaining agreement entered into by a partici16 pating hospital. 

17 ‘‘(k) REGULATIONS.— 

18 ‘‘(1) IN GENERAL.—The Secretary shall pro19 mulgate such regulations as are appropriate and 

20 necessary to implement this section. 

21 ‘‘(2) IMPLEMENTATION.— 

22 ‘‘(A) IN GENERAL.—Except as provided in 

23 subparagraph (B), as soon as practicable but 

24 not later than 2 years after the date of the en25 actment of this section, a participating hospital 


rfrederick on DSKBCBPHB2PROD with BILLS
23 

•S 2446 IS

1 shall have implemented a hospital-wide staffing 

2 plan for nursing services under this section. 

3 ‘‘(B) SPECIAL RULE FOR RURAL HOS4 PITALS.—In the case of a participating hospital 

5 located in a rural area (as defined in section 

6 1886(d)(2)(D)), such participating hospital 

7 shall have implemented a hospital-wide staffing 

8 plan for nursing services under this section as 

9 soon as practicable but not later than 4 years 

10 after the date of the enactment of this section. 

11 ‘‘(l) DEFINITIONS.—In this section: 

12 ‘‘(1) DECLARED STATE OF EMERGENCY.—The 

13 term ‘declared state of emergency’ means an offi14 cially designated state of emergency that has been 

15 declared by the Federal Government or the head of 

16 the appropriate State or local governmental agency 

17 having authority to declare that the State, county, 

18 municipality, or locality is in a state of emergency, 

19 but does not include a state of emergency that re20 sults from a labor dispute in the health care indus21 try or consistent understaffing. 

22 ‘‘(2) PARTICIPATING HOSPITAL.—The term 

23 ‘participating hospital’ means a hospital (as defined 

24 in section 1861(e)) that has entered into a provider 

25 agreement under section 1866. 


rfrederick on DSKBCBPHB2PROD with BILLS
24 

•S 2446 IS

1 ‘‘(3) PERSON.—The term ‘person’ means one or 

2 more individuals, associations, corporations, unincor3 porated organizations, or labor unions. 

4 ‘‘(4) REGISTERED NURSE.—The term ‘reg5 istered nurse’ means an individual who has been 

6 granted a license to practice as a registered nurse in 

7 at least one State. 

8 ‘‘(5) SHIFT.—The term ‘shift’ means a sched9 uled set of hours or duty period to be worked at a 

10 participating hospital. 

11 ‘‘(6) UNIT.—The term ‘unit’ means, with re12 spect to a hospital, an organizational department or 

13 separate geographic area of a hospital, including a 

14 burn unit, a labor and delivery room, a post-anes15 thesia service area, an emergency department, an 

16 operating room, a pediatric unit, a stepdown or in17 termediate care unit, a specialty care unit, a telem18 etry unit, a general medical care unit, a subacute 

19 care unit, and a transitional inpatient care unit.’’. 

Æ 


rfrederick on DSKBCBPHB2PROD with BILLS