II 

114TH CONGRESS 

1ST SESSION S. 1132 

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 

APRIL 29, 2015 

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 ‘‘Registered Nurse Safe 

5 Staffing Act of 2015’’. 

6 SEC. 2. FINDINGS. 

7 Congress makes the following findings: 

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1 (1) Research shows that patient safety in hos2 pitals is directly proportionate to the number of reg3 istered nurses working in the hospital. Higher staff4 ing levels by experienced registered nurses are re5 lated to lower rates of negative patient outcomes. 

6 (2) A 2011 study on nurse staffing and inpa7 tient hospital mortality shows that sub-optimal nurse 

8 staffing is linked with a greater likelihood of patient 

9 death in the hospital. A 2012 study of serious pa10 tient events reported to the Joint Commission dem11 onstrates that one of the leading causes of all hos12 pital sentinel events is human factors, including 

13 staffing and staffing skill mix. 

14 (3) Health care worker fatigue has been identi15 fied as a major patient safety hazard, and appro16 priate staffing policies and practices are indicated as 

17 an effective strategy to reduce health care worker fa18 tigue and to protect patients. A national survey of 

19 registered nurses found that 74 percent experience 

20 acute or chronic effects of stress and overwork. 

21 (4) A strategy that ensures optimal nurse staff22 ing and skill mix greatly influences patient satisfac23 tion and results in greater overall savings to hos24 pitals through reductions in adverse patient events. 

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1 (5) A 2009 study demonstrated that improved 

2 patient satisfaction due to increased and appropriate 

3 nurse staffing is reflected on hospital scores on 

4 HCAHPS, which is a key measure for value-based 

5 payment programs under the Medicare program and 

6 used by other payors. 

7 (6) Registered nurses play a vital role in pre8 venting patient care errors. A 2009 study found that 

9 sufficient staffing of critical care nurses can prevent 

10 adverse patient events, which can cost anywhere 

11 from $2,200,000 to $13,200,000. By contrast, the 

12 nurse staffing costs in the study time period were 

13 only $1,360,000. 

14 (7) Higher nurse staffing also generates cost 

15 savings to payors, as demonstrated in a 2011 cost16 benefit analysis that weighed registered nursing per17 sonnel costs against emergency department utiliza18 tion after patient discharge from a hospital. 

19 (8) A 2012 study of Pennsylvania hospitals 

20 shows that by reducing nurse burnout, which is at21 tributed in part to poor nurse staffing, those hos22 pitals could prevent an estimated 4,160 infections 

23 with an associated savings of $41,000,000. That 

24 study also found that for each additional patient as25 signed to a registered nurse for care, there is an inmstockstill on DSK4VPTVN1PROD with BILLS

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1 cidence of roughly one additional catheter-acquired 

2 urinary tract infection per 1,000 patients or 1,351 

3 infections per year, costing those hospitals as much 

4 as $1,100,000 annually. 

5 (9) When hospitals employ insufficient numbers 

6 of nursing staff, registered nurses are being required 

7 to perform professional services under conditions 

8 that do not support quality health care or a health9 ful work environment for registered nurses. 

10 (10) As a payor for inpatient and outpatient 

11 hospital services furnished to Medicare beneficiaries, 

12 the Federal Government has a compelling interest in 

13 promoting the safety of these patients by requiring 

14 any hospital participating in the Medicare program 

15 to establish minimum safe staffing levels for reg16 istered nurses. 

17 SEC. 3. ESTABLISHMENT OF SAFE NURSE STAFFING LEV18 ELS BY MEDICARE PARTICIPATING HOS19 PITALS. 

20 (a) REQUIREMENT OF MEDICARE PROVIDER AGREE21 MENT.—Section 1866(a)(1) of the Social Security Act (42 

22 U.S.C. 1395cc(a)(1)) is amended— 

23 (1) in subparagraph (V), by striking ‘‘and’’ at 

24 the end; 

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

2 3005 of the Patient Protection and Affordable Care 

3 Act (Public Law 111–148)— 

4 (A) by moving such subparagraph 2 ems to 

5 the left; and 

6 (B) by striking the period at the end; 

7 (3) in subparagraph (W), as added by section 

8 6406(b) of the Patient Protection and Affordable 

9 Care Act (Public Law 111–148)— 

10 (A) by moving such subparagraph 2 ems to 

11 the left; 

12 (B) by redesignating such subparagraph as 

13 subparagraph (X); and 

14 (C) by striking the period at the end and 

15 inserting ‘‘, and’’; and 

16 (4) by inserting after subparagraph (X), as re17 designated by paragraph (3)(B), the following new 

18 subparagraph: 

19 ‘‘(Y) in the case of a hospital (as defined in sec20 tion 1861(e)), to meet the requirements of section 

21 1899C.’’. 

22 (b) REQUIREMENTS.—Title XVIII of the Social Secu23 rity Act (42 U.S.C. 1395 et seq.) is amended by adding 

24 at the end the following new section: 

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1 ‘‘NURSE STAFFING REQUIREMENTS FOR MEDICARE

2 PARTICIPATING HOSPITALS

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

4 STAFFING PLAN.— 

5 ‘‘(1) IN GENERAL.—Each participating hospital 

6 shall implement a hospital-wide staffing plan for 

7 nursing services furnished in the hospital. 

8 ‘‘(2) REQUIREMENT FOR DEVELOPMENT OF

9 STAFFING PLAN BY HOSPITAL NURSE STAFFING

10 COMMITTEE.—The hospital-wide staffing plan for 

11 nursing services implemented by a hospital pursuant 

12 to paragraph (1)— 

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

14 nurse staffing committee established under sub15 section (b); and 

16 ‘‘(B) shall require that an appropriate 

17 number of registered nurses provide direct pa18 tient care in each unit and on each shift of the 

19 hospital to ensure staffing levels that— 

20 ‘‘(i) address the unique characteristics 

21 of the patients and hospital units; and 

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

23 quality patient care, consistent with the re24 quirements under subsection (c). 

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

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1 ‘‘(1) ESTABLISHMENT.—Each participating 

2 hospital shall establish a hospital nurse staffing 

3 committee (hereinafter in this section referred to as 

4 the ‘Committee’). 

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

6 pursuant to this subsection shall be composed of 

7 members as follows: 

8 ‘‘(A) MINIMUM 55 PERCENT NURSE PAR9 TICIPATION.—Not less than 55 percent of the 

10 members of the Committee shall be registered 

11 nurses who provide direct patient care but who 

12 are neither hospital nurse managers nor part of 

13 the hospital administration staff. 

14 ‘‘(B) INCLUSION OF HOSPITAL NURSE

15 MANAGERS.—The Committee shall include 

16 members who are hospital nurse managers. 

17 ‘‘(C) INCLUSION OF NURSES FROM SPE18 CIALTY UNITS.—The members of the Com19 mittee shall include at least 1 registered nurse 

20 who provides direct care from each nurse spe21 cialty or unit of the hospital (each such spe22 cialty or unit as determined by the hospital). 

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

24 Committee shall include such other personnel of 

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1 the hospital as the hospital determines to be ap2 propriate. 

3 ‘‘(3) DUTIES.— 

4 ‘‘(A) DEVELOPMENT OF STAFFING

5 PLAN.—The Committee shall develop a hospital6 wide staffing plan for nursing services furnished 

7 in the hospital consistent with the requirements 

8 under subsection (c). 

9 ‘‘(B) REVIEW AND MODIFICATION OF

10 STAFFING PLAN.—The Committee shall— 

11 ‘‘(i) conduct regular, ongoing moni12 toring of the implementation of the hos13 pital-wide staffing plan for nursing services 

14 furnished in the hospital; 

15 ‘‘(ii) carry out evaluations of the hos16 pital-wide staffing plan for nursing services 

17 at least annually; and 

18 ‘‘(iii) make such modifications to the 

19 hospital-wide staffing plan for nursing 

20 services as may be appropriate. 

21 ‘‘(C) ADDITIONAL DUTIES.—The Com22 mittee shall— 

23 ‘‘(i) develop policies and procedures 

24 for overtime requirements of registered 

25 nurses providing direct patient care and 

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1 for appropriate time and manner of relief 

2 of such registered nurses during routine 

3 absences; and 

4 ‘‘(ii) carry out such additional duties 

5 as the Committee determines to be appro6 priate. 

7 ‘‘(c) STAFFING PLAN REQUIREMENTS.— 

8 ‘‘(1) PLAN REQUIREMENTS.—Subject to para9 graph (2), a hospital-wide staffing plan for nursing 

10 services developed and implemented under this sec11 tion shall— 

12 ‘‘(A) be based upon input from the reg13 istered nurse staff of the hospital who provide 

14 direct patient care or their exclusive representa15 tives, as well as the chief nurse executive; 

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

17 and the level and variability of intensity of care 

18 to be provided to those patients, with appro19 priate consideration given to admissions, dis20 charges, and transfers during each shift; 

21 ‘‘(C) take into account contextual issues 

22 affecting nurse staffing and the delivery of care, 

23 including architecture and geography of the en24 vironment and available technology; 

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1 ‘‘(D) take into account the level of edu2 cation, training, and experience of those reg3 istered nurses providing direct patient care; 

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

5 and services provided by other health care per6 sonnel associated with nursing care, such as 

7 certified nurse assistants, licensed vocational 

8 nurses, licensed psychiatric technicians, nursing 

9 assistants, aides, and orderlies; 

10 ‘‘(F) take into account staffing levels rec11 ommended by specialty nursing organizations; 

12 ‘‘(G) establish upwardly adjustable min13 imum ratios of direct care registered nurses to 

14 patients for each unit and for each shift of the 

15 hospital, based upon an assessment by reg16 istered nurses of the level and variability of in17 tensity of care required by patients under exist18 ing conditions; 

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

20 level staffing, quality and patient outcome data, 

21 and national comparisons, as available; 

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

23 not be assigned to work in a particular unit of 

24 the hospital without first having established the 

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1 ability to provide professional care in such unit; 

2 and 

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

4 all requirements of the hospital-wide staffing 

5 plan for nursing services during a declared 

6 state of emergency (as defined in subsection 

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

8 to provide an exceptional level of emergency or 

9 other medical services. 

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

11 plan for nursing services developed and implemented 

12 under this section— 

13 ‘‘(A) shall not preempt any registered14 nurse staffing levels established under State law 

15 or regulation; and 

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

17 of registered nurses established under para18 graph (1)(G) as an upper limit on the nurse 

19 staffing of the hospital to which such minimum 

20 number applies. 

21 ‘‘(d) REPORTING AND RELEASE TO PUBLIC OF CER22 TAIN STAFFING INFORMATION.— 

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

24 participating hospital shall— 

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

2 visible place, a document that specifies in a uni3 form manner (as prescribed by the Secretary) 

4 the current number of licensed and unlicensed 

5 nursing staff directly responsible for patient 

6 care in each unit of the hospital, identifying 

7 specifically the number of registered nurses; 

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

9 public— 

10 ‘‘(i) the nursing staff information de11 scribed in subparagraph (A); 

12 ‘‘(ii) a detailed written description of 

13 the hospital-wide staffing plan imple14 mented by the hospital pursuant to sub15 section (a); and 

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

17 date on which an evaluation is carried out 

18 by the Committee under subsection 

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

20 and 

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

22 submit to the Secretary in a uniform manner 

23 (as prescribed by the Secretary) the nursing 

24 staff information described in subparagraph (A) 

25 through electronic data submission. 

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1 ‘‘(2) SECRETARIAL RESPONSIBILITIES.—The 

2 Secretary shall— 

3 ‘‘(A) make the information submitted pur4 suant to paragraph (1)(C) publicly available in 

5 a comprehensible format (as described in sub6 section (e)(2)(D)(ii)), including by publication 

7 on the Hospital Compare Internet Web site of 

8 the Department of Health and Human Services; 

9 and 

10 ‘‘(B) provide for the auditing of such infor11 mation for accuracy as a part of the process of 

12 determining whether the participating hospital 

13 is in compliance with the conditions of its 

14 agreement with the Secretary under section 

15 1866, including under subsection (a)(1)(Y) of 

16 such section. 

17 ‘‘(e) RECORDKEEPING; COLLECTION AND REPORT18 ING OF QUALITY DATA; EVALUATION.— 

19 ‘‘(1) RECORDKEEPING.—Each participating 

20 hospital shall maintain for a period of at least 3 

21 years (or, if longer, until the conclusion of any pend22 ing enforcement activities) such records as the Sec23 retary deems necessary to determine whether the 

24 hospital has implemented a hospital-wide staffing 

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

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1 ‘‘(2) COLLECTION AND REPORTING OF QUALITY

2 DATA ON NURSING SERVICES.— 

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

4 require the collection, aggregation, mainte5 nance, and reporting of quality data relating to 

6 nursing services furnished by each participating 

7 hospital. 

8 ‘‘(B) USE OF ENDORSED MEASURES.—In 

9 carrying out this paragraph, the Secretary shall 

10 use only quality measures for nursing-sensitive 

11 care that are endorsed by the consensus-based 

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

13 ‘‘(C) USE OF QUALIFIED THIRD-PARTY EN14 TITIES FOR COLLECTION AND SUBMISSION OF

15 DATA.— 

16 ‘‘(i) IN GENERAL.—A participating 

17 hospital may enter into agreements with 

18 third-party entities that have demonstrated 

19 expertise in the collection and submission 

20 of quality data on nursing services to col21 lect, aggregate, maintain, and report the 

22 quality data of the hospital pursuant to 

23 subparagraph (A). 

24 ‘‘(ii) CONSTRUCTION.—Nothing in 

25 clause (i) shall be construed to excuse or 

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1 exempt a participating hospital that has 

2 entered into an agreement described in 

3 such clause from compliance with require4 ments for quality data collection, aggrega5 tion, maintenance, and reporting imposed 

6 under this paragraph. 

7 ‘‘(D) REPORTING OF QUALITY DATA.— 

8 ‘‘(i) PUBLICATION ON HOSPITAL COM9 PARE WEB SITE.—Subject to the suc10 ceeding provisions of this subparagraph, 

11 the Secretary shall make the data sub12 mitted pursuant to subparagraph (A) pub13 licly available, including by publication on 

14 the Hospital Compare Internet Web site of 

15 the Department of Health and Human 

16 Services. 

17 ‘‘(ii) COMPREHENSIBLE FORMAT.— 

18 Data made available to the public under 

19 clause (i) shall be presented in a clearly 

20 understandable format that permits con21 sumers of hospital services to make mean22 ingful comparisons among hospitals, in23 cluding concise explanations in plain 

24 English of how to interpret the data, of the 

25 difference in types of nursing staff, of the 

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1 relationship between nurse staffing levels 

2 and quality of care, and of how nurse 

3 staffing may vary based on patient case 

4 mix. 

5 ‘‘(iii) OPPORTUNITY TO CORRECT ER6 RORS.—The Secretary shall establish a 

7 process under which participating hospitals 

8 may review data submitted to the Sec9 retary pursuant to subparagraph (A) to 

10 correct errors, if any, contained in that 

11 data submission before making the data 

12 available to the public under clause (i). 

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

14 shall provide for the analysis of quality data col15 lected from participating hospitals under paragraph 

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

17 staffing plans for nursing services implemented pur18 suant to subsection (a) on— 

19 ‘‘(A) patient outcomes that are nursing 

20 sensitive (such as pressure ulcers, fall occur21 rence, falls resulting in injury, length of stay, 

22 and central line catheter infections); and 

23 ‘‘(B) nursing workforce safety and reten24 tion (including work-related injury, staff skill 

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1 cancy and voluntary turnover rates, overtime 

2 rates, use of temporary agency personnel, and 

3 nurse satisfaction). 

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

5 to accept an assignment as a nurse in a participating hos6 pital, or in a unit of a participating hospital, if— 

7 ‘‘(1) the assignment is in violation of the hos8 pital-wide staffing plan for nursing services imple9 mented pursuant to subsection (a); or 

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

11 training, or experience to fulfill the assignment with12 out compromising the safety of any patient or jeop13 ardizing the license of the nurse. 

14 ‘‘(g) ENFORCEMENT.— 

15 ‘‘(1) RESPONSIBILITY.—The Secretary shall en16 force the requirements and prohibitions of this sec17 tion in accordance with the succeeding provisions of 

18 this subsection. 

19 ‘‘(2) PROCEDURES FOR RECEIVING AND INVES20 TIGATING COMPLAINTS.—The Secretary shall estab21 lish procedures under which— 

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

23 a participating hospital has violated a require24 ment of or a prohibition under this section; and 

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1 ‘‘(B) such complaints are investigated by 

2 the Secretary. 

3 ‘‘(3) REMEDIES.—Except as provided in para4 graph (5), if the Secretary determines that a partici5 pating hospital has violated a requirement of this 

6 section, the Secretary— 

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

8 a corrective action plan to prevent the recur9 rence of such violation; and 

10 ‘‘(B) may impose civil money penalties 

11 under paragraph (4). 

12 ‘‘(4) CIVIL MONEY PENALTIES.— 

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

14 other penalties prescribed by law, the Secretary 

15 may impose a civil money penalty of not more 

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

17 requirement of this section, except that the Sec18 retary shall impose a civil money penalty of 

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

20 the case of a participating hospital that the 

21 Secretary determines has a pattern or practice 

22 of such violations (with the amount of such ad23 ditional penalties being determined in accord24 ance with a schedule or methodology specified 

25 in regulations). 

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

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

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

4 this paragraph in the same manner as such 

5 provisions apply to a penalty or proceeding 

6 under section 1128A. 

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

8 ‘‘(i) INTERNET WEB SITE.—The Sec9 retary shall publish on an appropriate 

10 Internet Web site of the Department of 

11 Health and Human Services the names of 

12 participating hospitals on which civil 

13 money penalties have been imposed under 

14 this section, the violation for which the 

15 penalty was imposed, and such additional 

16 information as the Secretary determines 

17 appropriate. 

18 ‘‘(ii) CHANGE OF OWNERSHIP.—With 

19 respect to a participating hospital that had 

20 a change in ownership, as determined by 

21 the Secretary, penalties imposed on the 

22 hospital while under previous ownership 

23 shall no longer be published by the Sec24 retary of such Internet Web site after the 

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1 1-year period beginning on the date of the 

2 change in ownership. 

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

4 REPORT QUALITY DATA ON NURSING SERVICES.— 

5 ‘‘(A) IN GENERAL.—In the case of a par6 ticipating hospital that fails to comply with re7 quirements under subsection (e)(2) to collect, 

8 aggregate, maintain, and report quality data re9 lating to nursing services furnished by the hos10 pital, instead of the remedies described in para11 graph (3), the provisions of subparagraph (B) 

12 shall apply with respect to each such failure of 

13 the participating hospital. 

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

15 by a participating hospital to comply with the 

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

17 each such failure shall be deemed to be a failure 

18 to submit data required under section 

19 1833(t)(17)(A), section 1886(b)(3)(B)(viii), 

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

21 1886(m)(5)(A), as the case may be, with re22 spect to the participating hospital involved for 

23 that year. 

24 ‘‘(h) WHISTLEBLOWER PROTECTIONS.— 

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1 ‘‘(1) PROHIBITION OF DISCRIMINATION AND

2 RETALIATION.—A participating hospital shall not 

3 discriminate or retaliate in any manner against any 

4 patient or employee of the hospital because that pa5 tient or employee, or any other person, has pre6 sented a grievance or complaint, or has initiated or 

7 cooperated in any investigation or proceeding of any 

8 kind, relating to— 

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

10 nursing services developed and implemented 

11 under this section; or 

12 ‘‘(B) any right, other requirement or pro13 hibition under this section, including a refusal 

14 to accept an assignment described in subsection 

15 (f). 

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

17 An employee of a participating hospital who has 

18 been discriminated or retaliated against in employ19 ment in violation of this subsection may initiate judi20 cial action in a United States district court and shall 

21 be entitled to reinstatement, reimbursement for lost 

22 wages, and work benefits caused by the unlawful 

23 acts of the employing hospital. Prevailing employees 

24 are entitled to reasonable attorney’s fees and costs 

25 associated with pursuing the case. 

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

2 patient who has been discriminated or retaliated 

3 against in violation of this subsection may initiate 

4 judicial action in a United States district court. A 

5 prevailing patient shall be entitled to liquidated 

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

7 addition to any other damages under other applica8 ble statutes, regulations, or common law. Prevailing 

9 patients are entitled to reasonable attorney’s fees 

10 and costs associated with pursuing the case. 

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

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

13 years after the discrimination or retaliation with re14 spect to which the action is brought. 

15 ‘‘(5) TREATMENT OF ADVERSE EMPLOYMENT

16 ACTIONS.—For purposes of this subsection— 

17 ‘‘(A) an adverse employment action shall 

18 be treated as discrimination or retaliation; and 

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

20 includes— 

21 ‘‘(i) the failure to promote an indi22 vidual or provide any other employment-re23 lated benefit for which the individual would 

24 otherwise be eligible; 

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1 ‘‘(ii) an adverse evaluation or decision 

2 made in relation to accreditation, certifi3 cation, credentialing, or licensing of the in4 dividual; and 

5 ‘‘(iii) a personnel action that is ad6 verse to the individual concerned. 

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

8 this section shall be construed as exempting or relieving 

9 any person from any liability, duty, penalty, or punish10 ment provided by the law of any State or political subdivi11 sion of a State, other than any such law which purports 

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

13 ‘‘(j) RELATIONSHIP TO CONDUCT PROHIBITED

14 UNDER THE NATIONAL LABOR RELATIONS ACT OR

15 OTHER COLLECTIVE BARGAINING LAWS.—Nothing in 

16 this section shall be construed as— 

17 ‘‘(1) permitting conduct prohibited under the 

18 National Labor Relations Act or under any other 

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

20 ‘‘(2) preempting, limiting, or modifying a collec21 tive bargaining agreement entered into by a partici22 pating hospital. 

23 ‘‘(k) REGULATIONS.— 

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1 ‘‘(1) IN GENERAL.—The Secretary shall pro2 mulgate such regulations as are appropriate and 

3 necessary to implement this section. 

4 ‘‘(2) IMPLEMENTATION.— 

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

6 subparagraph (B), as soon as practicable but 

7 not later than 2 years after the date of the en8 actment of this section, a participating hospital 

9 shall have implemented a hospital-wide staffing 

10 plan for nursing services under this section. 

11 ‘‘(B) SPECIAL RULE FOR RURAL HOS12 PITALS.—In the case of a participating hospital 

13 located in a rural area (as defined in section 

14 1886(d)(2)(D)), such participating hospital 

15 shall have implemented a hospital-wide staffing 

16 plan for nursing services under this section as 

17 soon as practicable but not later than 4 years 

18 after the date of the enactment of this section. 

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

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

21 term ‘declared state of emergency’ means an offi22 cially designated state of emergency that has been 

23 declared by the Federal Government or the head of 

24 the appropriate State or local governmental agency 

25 having authority to declare that the State, county, 

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

2 but does not include a state of emergency that re3 sults from a labor dispute in the health care indus4 try or consistent understaffing. 

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

6 ‘participating hospital’ means a hospital (as defined 

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

8 agreement under section 1866. 

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

10 more individuals, associations, corporations, unincor11 porated organizations, or labor unions. 

12 ‘‘(4) REGISTERED NURSE.—The term ‘reg13 istered nurse’ means an individual who has been 

14 granted a license to practice as a registered nurse in 

15 at least 1 State. 

16 ‘‘(5) SHIFT.—The term ‘shift’ means a sched17 uled set of hours or duty period to be worked at a 

18 participating hospital. 

19 ‘‘(6) UNIT.—The term ‘unit’ means, with re20 spect to a hospital, an organizational department or 

21 separate geographic area of a hospital, including a 

22 burn unit, a labor and delivery room, a post-anes23 thesia service area, an emergency department, an 

24 operating room, a pediatric unit, a stepdown or in25 termediate care unit, a specialty care unit, a telemmstockstill on DSK4VPTVN1PROD with BILLS

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1 etry unit, a general medical care unit, a subacute 

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

Æ 

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