II 

118TH CONGRESS 

1ST SESSION S. 1113 

To amend the Public Health Service Act to establish direct care registered 

nurse-to-patient staffing ratio requirements in hospitals, and for other 

purposes. 

IN THE SENATE OF THE UNITED STATES 

MARCH 30, 2023 

Mr. BROWN (for himself, Ms. BALDWIN, Ms. WARREN, Mr. PADILLA, Ms. 

STABENOW, Mr. MARKEY, and Mr. SANDERS) introduced the following 

bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions 

A BILL 

To amend the Public Health Service Act to establish direct 

care registered nurse-to-patient staffing ratio requirements in hospitals, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS; FINDINGS. 

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

5 ‘‘Nurse Staffing Standards for Hospital Patient Safety 

6 and Quality Care Act of 2023’’. 

7 (b) TABLE OF CONTENTS.—The table of contents for 

8 this Act is as follows: 


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Sec. 1. Short title; table of contents; findings. 

Sec. 2. Minimum direct care registered nurse staffing requirement. 

Sec. 3. Enforcement of requirements through Federal programs. 

Sec. 4. Nurse workforce initiative. 

1 (c) FINDINGS.—Congress finds the following: 

2 (1) The Federal Government has a substantial 

3 interest in promoting quality care and improving the 

4 delivery of health care services to patients in health 

5 care facilities in the United States. 

6 (2) Recent changes in health care delivery sys7 tems that have resulted in higher acuity levels 

8 among patients in health care facilities increase the 

9 need for improved quality measures in order to pro10 tect patient care and reduce the incidence of medical 

11 errors. 

12 (3) Inadequate and poorly monitored registered 

13 nurse staffing practices that result in too few reg14 istered nurses providing direct care jeopardize the 

15 delivery of quality health care services. 

16 (4) Numerous studies have shown that patient 

17 outcomes are directly correlated to direct care reg18 istered nurse staffing levels, including a 2010 

19 Health Services Research study that concluded that 

20 implementation of minimum nurse-to-patient staff21 ing ratios in California has led to improved patient 

22 outcomes and nurse retention and a 2014 Agency 

23 for Healthcare Research and Quality study that conVerDate Sep 11 2014 06:08 Apr 11, 2023 Jkt 039200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S1113.IS S1113

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1 cluded increases in nurse staffing and skill mix lead 

2 to improved quality and reduced length of stay at no 

3 additional cost. 

4 (5) Requirements for direct care registered 

5 nurse staffing ratios will help address the registered 

6 nurse shortage in the United States by aiding in re7 cruitment of new registered nurses and improving 

8 retention of registered nurses who are considering 

9 leaving direct patient care because of demands cre10 ated by inadequate staffing. 

11 (6) Establishing adequate minimum direct care 

12 registered nurse-to-patient ratios that take into ac13 count patient acuity measures will improve the deliv14 ery of quality health care services and guarantee pa15 tient safety. 

16 (7) Establishing safe staffing standards for di17 rect care registered nurses is a critical component of 

18 assuring that there is adequate hospital staffing at 

19 all levels to improve the delivery of quality care and 

20 protect patient safety. 

21 SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE 

22 STAFFING REQUIREMENT. 

23 (a) MINIMUM DIRECT CARE REGISTERED NURSE

24 STAFFING REQUIREMENTS.—The Public Health Service 


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

2 end the following new title: 

3 ‘‘TITLE XXXIV—MINIMUM DI4 RECT CARE REGISTERED 

5 NURSE STAFFING REQUIRE6 MENT 

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

8 ‘‘(a) STAFFING PLAN.— 

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

10 a staffing plan that— 

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

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

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

15 this title. 

16 ‘‘(2) EFFECTIVE DATES.— 

17 ‘‘(A) IMPLEMENTATION OF STAFFING

18 PLAN.—Subject to subparagraph (B), the re19 quirements under paragraph (1) shall take ef20 fect on a date to be determined by the Sec21 retary, but not later than 1 year after the date 

22 of the enactment of this title. 

23 ‘‘(B) APPLICATION OF MINIMUM DIRECT

24 CARE REGISTERED NURSE-TO-PATIENT RA25 TIOS.—The requirements under subsection (b) 


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1 shall take effect as soon as practicable, as de2 termined by the Secretary, but not later than— 

3 ‘‘(i) 2 years after the date of enact4 ment of this title; and 

5 ‘‘(ii) in the case of a hospital in a 

6 rural area (as defined in section 

7 1886(d)(2)(D) of the Social Security Act), 

8 4 years after the date of enactment of this 

9 title. 

10 ‘‘(b) MINIMUM DIRECT CARE REGISTERED NURSE11 TO-PATIENT RATIOS.— 

12 ‘‘(1) IN GENERAL.—Except as provided in para13 graph (4) and other provisions of this section, a hos14 pital’s staffing plan shall provide that, at all times 

15 during each shift within a unit of the hospital, and 

16 with a full complement of ancillary and support 

17 staff, a direct care registered nurse may be assigned 

18 to not more than the following number of patients 

19 in that unit: 

20 ‘‘(A) One patient in trauma emergency 

21 units. 

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

23 provided that a minimum of 1 additional person 

24 serves as a scrub assistant in such unit. 


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1 ‘‘(C) Two patients in critical care units, in2 cluding neonatal intensive care units, emer3 gency critical care and intensive care units, 

4 labor and delivery units, coronary care units, 

5 acute respiratory care units, postanesthesia 

6 units, and burn units. 

7 ‘‘(D) Three patients in emergency room 

8 units, pediatrics units, stepdown units, telem9 etry units, antepartum units, and combined 

10 labor, deliver, and postpartum units. 

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

12 units, intermediate care nursery units, acute 

13 care psychiatric units, and other specialty care 

14 units. 

15 ‘‘(F) Five patients in rehabilitation units 

16 and skilled nursing units. 

17 ‘‘(G) Six patients in postpartum (3 cou18 plets) units and well-baby nursery units. 

19 ‘‘(2) SIMILAR UNITS WITH DIFFERENT

20 NAMES.—The Secretary may apply minimum direct 

21 care registered nurse-to-patient ratios established in 

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

23 paragraph to a type of hospital unit not referred to 

24 in such paragraph if such type of hospital unit pro25 vides a level of care to patients whose needs are 


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1 similar to the needs of patients cared for in the hos2 pital unit referred to in such paragraph. 

3 ‘‘(3) APPLICATION OF RATIOS TO HOSPITAL

4 NURSING PRACTICE STANDARDS.— 

5 ‘‘(A) IN GENERAL.—A patient assignment 

6 may be included in the calculation of the direct 

7 care registered nurse-to-patient ratios required 

8 in this subsection only if care is provided by a 

9 direct care registered nurse and the provision of 

10 care to the particular patient is within that di11 rect care registered nurse’s competence. 

12 ‘‘(B) DEMONSTRATION OF UNIT-SPECIFIC

13 COMPETENCE.—A hospital shall not assign a di14 rect care registered nurse to a hospital unit un15 less that hospital determines that the direct 

16 care registered nurse has demonstrated current 

17 competence in providing care in that unit, and 

18 has also received orientation to that hospital’s 

19 unit sufficient to provide competent care to pa20 tients in that unit. 

21 ‘‘(C) DUTIES OF THE ASSIGNED DIRECT

22 CARE REGISTERED NURSE.—Each patient shall 

23 be assigned to a direct care registered nurse 

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1 tion of the nursing care provided to the patient 

2 at least every shift and has the responsibility 

3 for the provision of care to a particular patient 

4 within his or her scope of practice. 

5 ‘‘(D) NURSE ADMINISTRATORS AND SU6 PERVISORS.—A registered nurse who is a nurse 

7 administrator, nurse supervisor, nurse manager, 

8 charge nurse, case manager, or any other hos9 pital administrator or supervisor, shall not be 

10 included in the calculation of the direct care 

11 registered nurse-to-patient ratio unless that 

12 nurse has a current and active direct patient 

13 care assignment and provides direct patient 

14 care in compliance with the requirements of this 

15 section, including competency requirements. 

16 The exemption in this subsection shall apply 

17 only during the hours in which the individual 

18 registered nurse has the principal responsibility 

19 of providing direct patient care and has no ad20 ditional job duties as would a direct care reg21 istered nurse. 

22 ‘‘(E) OTHER PERSONNEL.—Other per23 sonnel may perform patient care tasks based on 

24 their training and demonstrated skill but may 

25 not perform or assist in direct care registered 


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1 nurse functions unless authorized to do in ac2 cordance with State scope of practice laws and 

3 regulations. 

4 ‘‘(F) TEMPORARY NURSING PERSONNEL.— 

5 A hospital shall not assign any nursing per6 sonnel from temporary nursing agencies patient 

7 care to any hospital unit without such personnel 

8 having demonstrated competence on the as9 signed unit and received orientation to that hos10 pital’s unit sufficient to provide competent care 

11 to patients in that unit. 

12 ‘‘(G) ANCILLARY AND ADDITIONAL STAFF13 ING.—The need for additional staffing of direct 

14 care registered nurses, licensed vocational or 

15 practical nurses, licensed psychiatric techni16 cians, certified nursing or patient care assist17 ants, or other licensed or unlicensed ancillary 

18 staff above the minimum registered nurse-to-pa19 tient ratios shall be based on the assessment of 

20 the individual patient’s nursing care require21 ment, the individual patient’s nursing care plan, 

22 and acuity level. 

23 ‘‘(4) RESTRICTIONS.— 

24 ‘‘(A) PROHIBITION AGAINST AVERAGING.— 

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1 tients and the total number of direct care reg2 istered nurses assigned to patients in a hospital 

3 unit during any 1 shift or over any period of 

4 time for purposes of meeting the requirements 

5 under this subsection. 

6 ‘‘(B) PROHIBITION AGAINST IMPOSITION

7 OF MANDATORY OVERTIME REQUIREMENTS.—A 

8 hospital shall not impose mandatory overtime 

9 requirements to meet the hospital unit direct 

10 care registered nurse-to-patient ratios required 

11 under this subsection. 

12 ‘‘(C) RELIEF DURING ROUTINE AB13 SENCES.—A hospital shall ensure that only a 

14 direct care registered nurse who has dem15 onstrated current competence to the hospital in 

16 providing care on a particular unit and has also 

17 received orientation to that hospital’s unit suffi18 cient to provide competent care to patients in 

19 that unit may relieve another direct care reg20 istered nurse during breaks, meals, and other 

21 routine, expected absences from a hospital unit. 

22 ‘‘(D) APPLICATION OF DIRECT CARE REG23 ISTERED NURSE-TO-PATIENT RATIOS IN PA24 TIENT-ACUITY ADJUSTABLE UNITS.—Patients 

25 shall be cared for only on units or patient care 


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1 areas where the direct care registered nurse-to2 patient ratios meet the level of intensity, type 

3 of care, and the individual requirements and 

4 needs of each patient. Notwithstanding para5 graph (2), hospitals that provide patient care in 

6 units or patient care areas that are acuity 

7 adaptable or acuity adjustable shall apply the 

8 direct care registered nurse-to-patient ratio re9 quired in this section for the highest patient 

10 acuity level or level of care in that unit or pa11 tient care area, and shall comply with all other 

12 requirements of this section. 

13 ‘‘(E) USE OF VIDEO MONITORS.—A hos14 pital shall not employ video monitors or any 

15 form of electronic visualization of a patient as 

16 a substitute for the direct observation required 

17 for patient assessment by the direct care reg18 istered nurse or required for patient protection. 

19 Video monitors or any form of electronic visual20 ization of a patient shall not be included in the 

21 calculation of the direct care registered nurse22 to-patient ratio required in this subsection and 

23 shall not replace the requirement of paragraph 

24 (3)(D) that each patient shall be assigned to a 

25 direct care registered nurse who shall directly 


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1 provide the assessment, planning, supervision, 

2 implementation, and evaluation of the nursing 

3 care provided to the patient at least every shift 

4 and have the responsibility for the provision of 

5 care to a particular patient within his or her 

6 scope of practice. 

7 ‘‘(F) USE OF OTHER TECHNOLOGY.—A 

8 hospital shall not employ technology that sub9 stitutes for the assigned registered nurse’s pro10 fessional judgment in assessment, planning, im11 plementation, and evaluation of care. 

12 ‘‘(5) ADJUSTMENT OF RATIOS.— 

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

14 patient safety, the Secretary may prescribe reg15 ulations that— 

16 ‘‘(i) increase minimum direct care reg17 istered nurse-to-patient ratios under this 

18 subsection to reduce the number of pa19 tients that may be assigned to each direct 

20 care nurse; or 

21 ‘‘(ii) add minimum direct care reg22 istered nurse-to-patient ratios for units not 

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


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1 ‘‘(B) CONSULTATION.—Such regulations 

2 shall be prescribed after consultation with af3 fected hospitals and registered nurses. 

4 ‘‘(6) ANCILLARY AND ADDITIONAL STAFFING.— 

5 ‘‘(A) IN GENERAL.—The Secretary may 

6 prescribe regulations requiring additional staff7 ing of direct care registered nurses, licensed vo8 cational or practice nurses, licensed psychiatric 

9 technicians, certified nursing or patient care as10 sistants, or other licensed or unlicensed ancil11 lary staff above the minimum registered nurse12 to-patient ratios that is based on the assess13 ment of the individual patient’s nursing care 

14 needs, the individual patient’s nursing care 

15 plan, and acuity level. 

16 ‘‘(B) CONSULTATION.—Such regulations 

17 shall be prescribed after consultation with af18 fected hospitals, registered nurses, and ancillary 

19 staff. 

20 ‘‘(7) RELATIONSHIP TO STATE-IMPOSED RA21 TIOS.—Nothing in this title shall preempt State 

22 standards that the Secretary determines to be as 

23 stringent as Federal requirements for a staffing plan 

24 established under this title. Minimum direct care 

25 registered nurse-to-patient ratios established under 


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1 this subsection shall not preempt State requirements 

2 that the Secretary determines are as stringent as to 

3 Federal requirements for direct care registered 

4 nurse-to-patient ratios established under this title. 

5 ‘‘(8) EXEMPTION IN EMERGENCIES.—The re6 quirements established under this subsection shall 

7 not apply during a state of emergency if a hospital 

8 is requested or expected to provide an exceptional 

9 level of emergency or other medical services. If a 

10 hospital seeks to apply the exemption under this 

11 paragraph in response to a complaint filed against 

12 the hospital for a violation of the provisions of this 

13 title, the hospital must demonstrate that prompt and 

14 diligent efforts were made to maintain required 

15 staffing levels. The Secretary shall issue guidance to 

16 hospitals that describes situations that constitute a 

17 state of emergency for purposes of the exemption 

18 under this paragraph and shall establish necessary 

19 penalties for violations of this paragraph consistent 

20 with section 3406. 

21 ‘‘(c) DEVELOPMENT AND REEVALUATION OF STAFF22 ING PLAN.— 

23 ‘‘(1) CONSIDERATIONS IN DEVELOPMENT OF

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

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1 tient ratios above the minimum direct care reg2 istered nurse-to-patient ratios required under sub3 section (b) if appropriate based upon consideration 

4 of, at minimum, the following factors: 

5 ‘‘(A) The number of patients on a par6 ticular unit on a shift-by-shift basis. 

7 ‘‘(B) The acuity level and nursing care 

8 plan of patients on a particular unit on a shift9 by-shift basis. 

10 ‘‘(C) The anticipated admissions, dis11 charges, and transfers of patients during each 

12 shift that impacts direct patient care. 

13 ‘‘(D) Specialized experience required of di14 rect care registered nurses on a particular unit. 

15 ‘‘(E) Staffing levels and services provided 

16 by licensed vocational or practical nurses, li17 censed psychiatric technicians, certified nurse 

18 assistants, or other ancillary staff in meeting 

19 direct patient care needs not required by a di20 rect care registered nurse. 

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

22 practices, policies, and procedures by temporary 

23 agency direct care registered nurses used dur24 ing a shift. 


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

2 of patient care presented by physical layout. 

3 ‘‘(2) DOCUMENTATION OF STAFFING.—A hos4 pital shall specify the system used to document ac5 tual staffing in each unit for each shift. 

6 ‘‘(3) ANNUAL REEVALUATION OF PLAN.— 

7 ‘‘(A) IN GENERAL.—A hospital shall annu8 ally evaluate its staffing plan in each unit in re9 lation to actual patient care requirements. 

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

11 staffing plan to the extent appropriate based on 

12 such evaluation. 

13 ‘‘(4) TRANSPARENCY.— 

14 ‘‘(A) IN GENERAL.—Any staffing plan or 

15 method used to create and evaluate acuity-level 

16 and adopted by a hospital under this section 

17 shall be transparent in all respects, including 

18 disclosure of detailed documentation of the 

19 methodology used to determine nursing staff20 ing, identifying each factor, assumption, and 

21 value used in applying such methodology. 

22 ‘‘(B) PUBLIC AVAILABILITY.—The Sec23 retary shall establish procedures to provide that 

24 the documentation submitted under subsection 


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1 (d) is available for public inspection in its en2 tirety. 

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

4 staffing plan of a hospital— 

5 ‘‘(A) shall be developed and subsequent re6 evaluations shall be conducted under this sub7 section on the basis of input from direct care 

8 registered nurses at the hospital from each unit 

9 or patient care area; and 

10 ‘‘(B) where such nurses are represented 

11 through collective bargaining, shall require bar12 gaining with the applicable recognized or cer13 tified collective bargaining representative of 

14 such nurses. 

15 Nothing in this title shall be construed to permit 

16 conduct prohibited under the National Labor Rela17 tions Act (29 U.S.C. 151 et seq.) or chapter 71 of 

18 title 5, United States Code. 

19 ‘‘(6) STAFFING COMMITTEES.—If a hospital 

20 maintains a staffing committee, then the committee 

21 shall include at least one registered nurse from each 

22 hospital unit and shall be composed of at least 50 

23 percent direct care registered nurses. The staffing 

24 committee shall include meaningful representation of 

25 other direct care nonmanagement staff. Direct care 


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1 registered nurses who serve on the committee shall 

2 be selected by other direct care registered nurses 

3 from their unit. Other direct care nonmanagement 

4 staff shall be selected by other direct care non5 management staff. Participation on staffing commit6 tees shall be considered a part of the employee’s reg7 ularly scheduled workweek. 

8 ‘‘(d) SUBMISSION OF PLAN TO SECRETARY.—A hos9 pital shall submit to the Secretary its staffing plan and 

10 any annual updates under subsection (c)(3)(B). A feder11 ally operated hospital may submit its staffing plan 

12 through the department or agency operating the hospital. 

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

14 ‘‘(a) POSTING REQUIREMENTS.—In each unit, a hos15 pital shall post a uniform notice in a form specified by 

16 the Secretary in regulation that— 

17 ‘‘(1) explains requirements imposed under sec18 tion 3401; 

19 ‘‘(2) includes actual direct care registered 

20 nurse-to-patient ratios during each shift; 

21 ‘‘(3) includes the actual number and titles of di22 rect care registered nurses assigned during each 

23 shift; and 

24 ‘‘(4) is visible, conspicuous, and accessible to 

25 staff, patients, and the public. 


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1 ‘‘(b) RECORDS.— 

2 ‘‘(1) MAINTENANCE OF RECORDS.—Each hos3 pital shall maintain accurate records of actual direct 

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

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

6 shall include— 

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

8 ‘‘(B) the identity and duty hours of— 

9 ‘‘(i) each direct care registered nurse 

10 assigned to each patient in each unit in 

11 each shift; and 

12 ‘‘(ii) ancillary staff who are under the 

13 coordination of the direct care registered 

14 nurse; 

15 ‘‘(C) certification that each nurse received 

16 rest and meal breaks and the identity and duty 

17 hours of each direct care registered nurse who 

18 provided such relief; and 

19 ‘‘(D) a copy of each notice posted under 

20 subsection (a). 

21 ‘‘(2) AVAILABILITY OF RECORDS.—Each hos22 pital shall make its records maintained under para23 graph (1) available to— 

24 ‘‘(A) the Secretary; 


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1 ‘‘(B) registered nurses and their collective 

2 bargaining representatives (if any); and 

3 ‘‘(C) the public under regulations estab4 lished by the Secretary, or in the case of a fed5 erally operated hospital, under section 552 of 

6 title 5, United States Code (commonly known 

7 as the Freedom of Information Act). 

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

9 audits to ensure— 

10 ‘‘(1) implementation of the staffing plan in ac11 cordance with this title; and 

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

13 section. 

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

15 NURSE STAFFING REQUIREMENTS. 

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

17 shall comply with minimum direct care licensed practical 

18 nurse staffing requirements that the Secretary establishes 

19 for units in hospitals. Such staffing requirements shall be 

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

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

22 conducted under subsection (b). 

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

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

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1 search and Quality, shall complete a study of licensed 

2 practical nurse staffing and its effects on patient care in 

3 hospitals. The Director may contract with a qualified enti4 ty or organization to carry out such study under this para5 graph. The Director shall consult with licensed practical 

6 nurses and organizations representing licensed practical 

7 nurses regarding the design and conduct of the study. 

8 ‘‘(c) APPLICATION OF REGISTERED NURSE PROVI9 SIONS TO LICENSED PRACTICAL NURSE STAFFING RE10 QUIREMENTS.—Paragraphs (2), (4)(A), (4)(B), (4)(C), 

11 and (6) of section 3401(b), paragraphs (1), (2), (3), and 

12 (4) of section 3401(c), and section 3402 shall apply to 

13 the establishment and application of direct care licensed 

14 practical nurse staffing requirements under this section 

15 pursuant to the additional staffing requirements under 

16 subsection (b)(3)(G) of section 3401 and in the same man17 ner that they apply to the establishment and application 

18 of direct care registered nurse-to-patient ratios under sec19 tions 3401 and 3402. 

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

21 section shall take effect as soon as practicable, as deter22 mined by the Secretary, but not later than— 

23 ‘‘(1) 2 years after the date of the enactment of 

24 this title; and 


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1 ‘‘(2) in the case of a hospital in a rural area 

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

3 Security Act), 4 years after the date of the enact4 ment of this title. 

5 ‘‘(e) STUDY.—Not later than 1 year after the date 

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

7 through the Director of the Agency for Healthcare Re8 search and Quality shall complete a study of registered 

9 and practical nurse staffing requirements in clinics and 

10 other outpatient settings, and its effects on patient care 

11 in outpatient settings. The Director may contract with a 

12 qualified entity or organization to carry out such study 

13 under this subsection. The Director shall consult with reg14 istered nurses and licensed practice nurses working in out15 patient settings, including professional nursing associa16 tions and labor organizations representing both registered 

17 and practice nurses working in outpatient settings regard18 ing the design and conduct of the study. 

19 ‘‘SEC. 3404. ADJUSTMENT IN REIMBURSEMENT. 

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

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

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1 quirements imposed under sections 3401 through 3403. 

2 The amount of such payment adjustments shall take into 

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

5 under subsection (c). 

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

8 be appropriated such additional sums as are required for 

9 federally operated hospitals to comply with the additional 

10 requirements established under sections 3401 through 

11 3403. 

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

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

14 Payment Advisory Commission (established under section 

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

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

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

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

22 ‘‘(a) PROFESSIONAL OBLIGATION AND RIGHTS.—All 

23 nurses have a duty and right to act based on their profes24 sional judgment in accordance with State nursing laws 

25 and regulations of the State in which the direct nursing 


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1 care is being performed and to provide care in the exclu2 sive interests of the patients and to act as the patient’s 

3 advocate. 

4 ‘‘(b) ACCEPTANCE OF PATIENT CARE ASSIGN5 MENTS.—The nurse is responsible for providing com6 petent, safe, therapeutic, and effective nursing care to as7 signed patients. Before accepting a patient assignment, a 

8 nurse shall— 

9 ‘‘(1) have the necessary professional knowledge, 

10 judgment, skills, and ability to provide the required 

11 care; 

12 ‘‘(2) determine using professional judgment in 

13 accordance with State nursing laws and regulations 

14 of the State in which the direct nursing care is being 

15 performed whether the nurse is competent to per16 form the nursing care required; and 

17 ‘‘(3) determine whether acceptance of a patient 

18 assignment would expose the patient or nurse to risk 

19 of harm. 

20 ‘‘(c) OBJECTION TO OR REFUSAL OF ASSIGNMENT.— 

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

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

23 faith— 

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

25 violation of section 3401 or 3403; or 


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•S 1113 IS

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

2 training, or experience to fulfill the assignment with3 out compromising the safety of any patient or jeop4 ardizing the license of the nurse. 

5 ‘‘(d) RETALIATION FOR OBJECTION TO OR REFUSAL

6 OF ASSIGNMENT BARRED.— 

7 ‘‘(1) NO DISCHARGE, DISCRIMINATION, OR RE8 TALIATION.—No hospital shall discharge, retaliate, 

9 discriminate, or otherwise take adverse action in any 

10 manner with respect to any aspect of a nurse’s em11 ployment (as defined in section 3407), including dis12 charge, promotion, compensation, or terms, condi13 tions, or privileges of employment, based on the 

14 nurse’s refusal of a work assignment under sub15 section (c). 

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

17 shall file a complaint or a report against a nurse 

18 with a State professional disciplinary agency because 

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

20 subsection (c). 

21 ‘‘(e) CAUSE OF ACTION.—Any nurse, collective bar22 gaining representative, or legal representative of any nurse 

23 who has been discharged, discriminated against, or retali24 ated against in violation of subsection (d)(1) or against 

25 whom a complaint or report has been filed in violation of 


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•S 1113 IS

1 subsection (d)(2) may (without regard to whether a com2 plaint has been filed under subsection (f) of this section 

3 or subsection (b) of section 3406) bring a cause of action 

4 in a United States district court. A nurse who prevails 

5 on the cause of action shall be entitled to one or more 

6 of the following: 

7 ‘‘(1) Reinstatement. 

8 ‘‘(2) Reimbursement of lost wages, compensa9 tion, and benefits. 

10 ‘‘(3) Attorneys’ fees. 

11 ‘‘(4) Court costs. 

12 ‘‘(5) Other damages. 

13 ‘‘(f) COMPLAINT TO SECRETARY.—A nurse, patient, 

14 collective bargaining representative, or other individual 

15 may file a complaint with the Secretary against a hospital 

16 that violates the provisions of this title. For any complaint 

17 filed, the Secretary shall— 

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

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

20 as alleged in the complaint has occurred; and 

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

22 order that the complaining nurse or individual shall 

23 not suffer any discharge, retaliation, discrimination, 

24 or other adverse action prohibited by subsection (d) 

25 or subsection (h). 


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•S 1113 IS

1 ‘‘(g) TOLL-FREE TELEPHONE NUMBER.— 

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

3 for the establishment of a toll-free telephone hotline 

4 to provide information regarding the requirements 

5 under section 3401 through 3403 and to receive re6 ports of violations of such section. 

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

8 provide each patient admitted to the hospital for in9 patient care with the hotline described in paragraph 

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

11 hotline may be used to report inadequate staffing or 

12 care. 

13 ‘‘(h) PROTECTION FOR REPORTING.— 

14 ‘‘(1) PROHIBITION ON RETALIATION OR DIS15 CRIMINATION.—A hospital shall not discriminate or 

16 retaliate in any manner against any patient, em17 ployee, or contract employee of the hospital, or any 

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

19 good faith, individually or in conjunction with an20 other person or persons, has presented a grievance 

21 or complaint, or has initiated or cooperated in any 

22 investigation or proceeding of any governmental en23 tity, regulatory agency, or private accreditation 

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•S 1113 IS

1 tion relating to the care, services, or conditions of 

2 the hospital or of any affiliated or related facilities. 

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

4 this subsection, an individual shall be deemed to be 

5 acting in good faith if the individual reasonably be6 lieves— 

7 ‘‘(A) the information reported or disclosed 

8 is true; and 

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

10 or may occur. 

11 ‘‘(i) PROHIBITION ON INTERFERENCE WITH

12 RIGHTS.— 

13 ‘‘(1) EXERCISE OF RIGHTS.—It shall be unlaw14 ful for any hospital to— 

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

16 exercise, or attempt to exercise, by any person 

17 of any right provided or protected under this 

18 title; or 

19 ‘‘(B) coerce or intimidate any person re20 garding the exercise or attempt to exercise such 

21 right. 

22 ‘‘(2) OPPOSITION TO UNLAWFUL POLICIES OR

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

24 discriminate or retaliate against any person for op25 posing any hospital policy, practice, or actions which 


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•S 1113 IS

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

2 any provision of this title. 

3 ‘‘(3) PROHIBITION ON INTERFERENCE WITH

4 PROTECTED COMMUNICATIONS.—A hospital (or an 

5 individual representing a hospital) shall not make, 

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

7 practice which in any manner directly or indirectly 

8 prohibits, impedes, or discourages a direct care 

9 nurse from, or intimidates, coerces, or induces a di10 rect care nurse regarding, engaging in free speech 

11 activities or disclosing information as provided under 

12 this title. 

13 ‘‘(4) PROHIBITION ON INTERFERENCE WITH

14 COLLECTIVE ACTION.—A hospital (or an individual 

15 representing a hospital) shall not in any way inter16 fere with the rights of nurses to organize, bargain 

17 collectively, and engage in concerted activity under 

18 section 7 of the National Labor Relations Act (29 

19 U.S.C. 157). 

20 ‘‘(j) NOTICE.—A hospital shall post in an appropriate 

21 location in each unit a conspicuous notice in a form speci22 fied by the Secretary that— 

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

24 other individuals under this section; 


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•S 1113 IS

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

2 or other individual may file a complaint with the 

3 Secretary against a hospital that violates the provi4 sions of this title; and 

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

6 complaint. 

7 ‘‘(k) EFFECTIVE DATE.— 

8 ‘‘(1) REFUSAL; RETALIATION; CAUSE OF AC9 TION.— 

10 ‘‘(A) IN GENERAL.—Subsections (c) 

11 through (e) shall apply to objections and refus12 als occurring on or after the effective date of 

13 the provision of this title to which the objection 

14 or refusal relates. 

15 ‘‘(B) EXCEPTION.—Subsection (c)(2) shall 

16 not apply to objections or refusals in any hos17 pital before the requirements of section 3401(a) 

18 or 3403(a), as applicable, apply to that hos19 pital. 

20 ‘‘(2) PROTECTIONS FOR REPORTING.—Sub21 section (h)(1) shall apply to actions occurring on or 

22 after the effective date of the provision to which the 

23 violation relates, except that such subsection shall 

24 apply to initiation, cooperation, or participation in 


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•S 1113 IS

1 an investigation or proceeding on or after the date 

2 of enactment of this title. 

3 ‘‘(3) NOTICE.—Subsection (j) shall take effect 

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

5 ‘‘SEC. 3406. ENFORCEMENT. 

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

7 requirements and prohibitions of this title in accordance 

8 with this section. 

9 ‘‘(b) PROCEDURES FOR RECEIVING AND INVES10 TIGATING COMPLAINTS.—The Secretary shall establish 

11 procedures under which— 

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

13 that a hospital has violated a requirement or a pro14 hibition of this title; and 

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

16 the Secretary. 

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

18 hospital has violated a requirement of this title, the Sec19 retary— 

20 ‘‘(1) shall require the facility to establish a cor21 rective action plan to prevent the recurrence of such 

22 violation; and 

23 ‘‘(2) may impose civil money penalties, as de24 scribed in subsection (d). 

25 ‘‘(d) CIVIL PENALTIES.— 


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•S 1113 IS

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

2 penalties prescribed by law, the Secretary may im3 pose civil penalties as follows: 

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

5 may impose on a hospital found to be in viola6 tion of this title a civil money penalty of— 

7 ‘‘(i) not more than $25,000 for the 

8 first knowing violation of this title by such 

9 hospital; and 

10 ‘‘(ii) not more than $50,000 for any 

11 subsequent knowing violation of this title 

12 by such hospital. 

13 ‘‘(B) INDIVIDUAL LIABILITY.—The Sec14 retary may impose on an individual who— 

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

16 by the Secretary to have violated this title; 

17 and 

18 ‘‘(ii) knowingly violates this title, 

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

20 for each such violation by the individual. 

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

22 1128A of the Social Security Act (other than sub23 sections (a) and (b)) shall apply with respect to a 

24 civil money penalty or proceeding under this sub25 section in the same manner as such provisions apply 


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•S 1113 IS

1 with respect to a civil money penalty or proceeding 

2 under such section 1128A. 

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

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

5 publish on the internet website of the Department of 

6 Health and Human Services the names of hospitals 

7 on which a civil money penalty has been imposed 

8 under this section, the violation for which such pen9 alty was imposed, and such additional information 

10 as the Secretary determines appropriate. 

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

12 a hospital that had a change of ownership, as deter13 mined by the Secretary, penalties imposed on the 

14 hospital while under previous ownership shall no 

15 longer be published by the Secretary pursuant to 

16 paragraph (1) after the 1-year period beginning on 

17 the date of change of ownership. 

18 ‘‘(f) USE OF FUNDS.—Funds collected by the Sec19 retary pursuant to this section are authorized to be appro20 priated to carry out this title. 

21 ‘‘SEC. 3407. DEFINITIONS. 

22 ‘‘For purposes of this title: 

23 ‘‘(1) ACUITY LEVEL.—The term ‘acuity level’ 

24 means the determination, using a hospital acuity 

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•S 1113 IS

1 tablished in coordination with direct care registered 

2 nurses and made transparent pursuant to section 

3 3401(c)(4), of nursing care requirements, based on 

4 the assigned direct care registered nurse’s profes5 sional judgment of— 

6 ‘‘(A) the severity and complexity of an in7 dividual patient’s illness or injury; 

8 ‘‘(B) the need for specialized equipment; 

9 and 

10 ‘‘(C) the intensity of nursing interventions 

11 required. 

12 ‘‘(2) COMPETENCE.—The term ‘competence’ or 

13 ‘competent’ means the satisfactory application of the 

14 duties and responsibilities of a registered nurse in 

15 providing nursing care to specific patient popu16 lations and for acuity levels for each patient care 

17 unit or area pursuant to the State nursing laws and 

18 regulations of the State in which the direct nursing 

19 care is being performed. 

20 ‘‘(3) DIRECT CARE LICENSED PRACTICAL

21 NURSE.—The term ‘direct care licensed practical 

22 nurse’ means an individual who has been granted a 

23 license by at least one State to practice as a licensed 

24 practical nurse or a licensed vocational nurse and 

25 who provides bedside care for one or more patients. 


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•S 1113 IS

1 ‘‘(4) DIRECT CARE REGISTERED NURSE.—The 

2 term ‘direct care registered nurse’ means an indi3 vidual who has been granted a license by at least 

4 one State to practice as a registered nurse and who 

5 provides bedside care for one or more patients. 

6 ‘‘(5) EMPLOYMENT.—The term ‘employment’ 

7 includes the provision of services under a contract or 

8 other arrangement. 

9 ‘‘(6) HOSPITAL.—The term ‘hospital’ has the 

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

11 Social Security Act, and includes a hospital that is 

12 operated by the Department of Veterans Affairs, the 

13 Department of Defense, the Indian Health Services 

14 Program, or any other department or agency of the 

15 United States. 

16 ‘‘(7) NURSE.—The term ‘nurse’ means any di17 rect care registered nurse or direct care licensed 

18 practice nurse (as the case may be), regardless of 

19 whether or not the nurse is an employee. 

20 ‘‘(8) NURSING CARE PLAN.—The term ‘nursing 

21 care plan’ means a plan developed by the assigned 

22 direct care registered nurse (in accordance with 

23 nursing law in the State in which the nursing care 

24 is performed) that indicates the nursing care to be 

25 given to individual patients that— 


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•S 1113 IS

1 ‘‘(A) considers the acuity level of the pa2 tient; 

3 ‘‘(B) is developed in coordination with the 

4 patient, the patient’s family, or other represent5 atives when appropriate, and staff of other dis6 ciplines involved in the care of the patient; 

7 ‘‘(C) reflects all elements of the nursing 

8 process; and 

9 ‘‘(D) recommends the number and skill 

10 mix of additional licensed and unlicensed direct 

11 care staff needed to fully implement the nursing 

12 care plan. 

13 ‘‘(9) PROFESSIONAL JUDGMENT.—The term 

14 ‘professional judgment’ means, in accordance with 

15 State nursing laws and regulations of the State in 

16 which the direct nursing care is being performed, the 

17 direct care registered nurse’s application of knowl18 edge, expertise, and experience in conducting a com19 prehensive nursing assessment of each patient and 

20 in making independent decisions about patient care 

21 including the need for additional staff. 

22 ‘‘(10) STAFFING PLAN.—The term ‘staffing 

23 plan’ means a staffing plan required under section 

24 3401. 


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•S 1113 IS

1 ‘‘(11) STATE OF EMERGENCY.—The term ‘state 

2 of emergency’— 

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

4 an unpredictable or unavoidable occurrence at 

5 an unscheduled or unpredictable interval, relat6 ing to health care delivery and requiring imme7 diate medical interventions and care; and 

8 ‘‘(B) does not include a state of emergency 

9 that results from a labor dispute in the health 

10 care industry or consistent understaffing. 

11 ‘‘SEC. 3408. RULE OF CONSTRUCTION. 

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

13 disclosure of private and confidential patient information, 

14 if such disclosure is not authorized or required by other 

15 applicable law.’’. 

16 (b) RECOMMENDATIONS TO CONGRESS.—Not later 

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

18 Secretary of Health and Human Services shall submit to 

19 Congress a report containing recommendations for ensur20 ing that sufficient numbers of nurses are available to meet 

21 the requirements imposed by title XXXIV of the Public 

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

23 (c) REPORT BY HRSA.— 

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

25 the date of enactment of this Act, the Administrator 


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•S 1113 IS

1 of the Health Resources and Services Administra2 tion, in consultation with the National Health Care 

3 Workforce Commission, shall submit to Congress a 

4 report regarding the relationship between nurse 

5 staffing levels and nurse retention in hospitals. 

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

7 after the date of enactment of this Act, the Adminis8 trator of the Health Resources and Services Admin9 istration, in consultation with the National Health 

10 Care Workforce Commission, shall submit to Con11 gress an update of the report submitted under para12 graph (1). 

13 SEC. 3. ENFORCEMENT OF REQUIREMENTS THROUGH FED14 ERAL PROGRAMS. 

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

16 Social Security Act (42 U.S.C. 1395cc(a)(1)) is amend17 ed— 

18 (1) in subparagraph (X), by striking ‘‘, and’’ 

19 and inserting a comma; 

20 (2) in subparagraph (Y), by striking the period 

21 at the end and inserting ‘‘, and’’; and 

22 (3) by inserting after the subparagraph (Y) the 

23 following new subparagraph: 


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•S 1113 IS

1 ‘‘(Z) in the case of a hospital, to comply with 

2 the provisions of title XXXIV of the Public Health 

3 Service Act.’’. 

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

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

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

7 (85); 

8 (2) by striking the period at the end of para9 graph (86) and inserting ‘‘; and’’; and 

10 (3) by inserting after paragraph (86) the fol11 lowing new paragraph: 

12 ‘‘(87) provide that any hospital that receives a 

13 payment under such plan comply with the provisions 

14 of title XXXIV of the Public Health Service Act (re15 lating to minimum direct care registered nurse staff16 ing requirements).’’. 

17 (c) HEALTH BENEFITS PROGRAM OF THE DEPART18 MENT OF VETERANS AFFAIRS.—Section 8110(a) of title 

19 38, United States Code, is amended by adding at the end 

20 the following new paragraphs: 

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

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

23 of title XXXIV of the Public Health Service Act. 

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

25 section 7106 of title 5 shall preclude enforcement of the 


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•S 1113 IS

1 provisions of title XXXIV of the Public Health Service Act 

2 with respect to a Department hospital through grievance 

3 procedures negotiated in accordance with chapter 71 of 

4 title 5.’’. 

5 (d) HEALTH BENEFITS PROGRAM OF THE DEPART6 MENT OF DEFENSE.— 

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

8 United States Code, is amended by adding at the 

9 end the following new section: 

10 ‘‘§ 1110c. Staffing requirements 

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

12 that is a hospital, the hospital shall comply with the provi13 sions of title XXXIV of the Public Health Service Act.’’. 

14 (2) CLERICAL AMENDMENT.—The table of sec15 tions at the beginning of such chapter is amended 

16 by inserting after the item relating to section 1110b 

17 the following new item: 

‘‘1110c. Staffing requirements.’’. 

18 (e) INDIAN HEALTH SERVICES PROGRAM.—Title 

19 VIII of the Indian Health Care Improvement Act (25 

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

21 the following new section: 

22 ‘‘SEC. 833. STAFFING REQUIREMENTS. 

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

24 provisions of title XXXIV of the Public Health Service Act 


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•S 1113 IS

1 (relating to minimum direct care registered nurse staffing 

2 requirements).’’. 

3 (f) FEDERAL LABOR-MANAGEMENT RELATIONS.— 

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

5 United States Code, is amended by adding at the 

6 end the following: 

7 ‘‘(c) Nothing in this section shall preclude enforce8 ment of the provisions of title XXXIV of the Public Health 

9 Service Act through grievance procedures negotiated in ac10 cordance with section 7121.’’. 

11 (2) CONFORMING AMENDMENT.—Section 

12 7106(a) of title 5, United States Code, is amended 

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

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

15 SEC. 4. NURSE WORKFORCE INITIATIVE. 

16 (a) SCHOLARSHIP AND STIPEND PROGRAM.—Section 

17 846(d) of the Public Health Service Act (42 U.S.C. 

18 297n(d)) is amended— 

19 (1) in the subsection heading, by inserting 

20 ‘‘AND STIPEND’’ after ‘‘SCHOLARSHIP’’; and 

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

22 after ‘‘scholarships’’. 

23 (b) NURSE RETENTION GRANTS.—Section 831(c)(1) 

24 of the Public Health Service Act (42 U.S.C. 296p(c)(1)) 

25 is amended— 


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•S 1113 IS

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

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

3 RETENTION.—’’; 

4 (2) in subparagraph (B), by striking ‘‘; and’’ 

5 and inserting a semicolon; 

6 (3) in subparagraph (C), by striking the period 

7 and inserting a semicolon; and 

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

9 ‘‘(D) to provide additional support to 

10 nurses entering the workforce by implementing 

11 nursing preceptorship projects that establish a 

12 period of practical and clinical experiences and 

13 training for nursing students, newly hired 

14 nurses, and recent graduates of a direct care 

15 degree program for registered nurses; or 

16 ‘‘(E) to implement mentorship projects 

17 that assist new or transitional direct care reg18 istered nurses in adapting to the hospital set19 ting.’’. 

Æ 


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