I 

109TH CONGRESS 

1ST SESSION H. R. 1372

To amend title XVIII of the Social Security Act to impose minimum nurse 

staffing ratios in Medicare participating hospitals, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 17, 2005

Mrs. CAPPS (for herself and Mr. SIMMONS) introduced the following bill; 

which was referred to the Committee on Energy and Commerce, and in 

addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such 

provisions as fall within the jurisdiction of the committee concerned 

A BILL

To amend title XVIII of the Social Security Act to impose 

minimum nurse staffing ratios in Medicare participating 

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. 

4 This Act may be cited as the ‘‘Quality Nursing Care 

5 Act of 2005’’. 

6 SEC. 2. FINDINGS. 

7 The Congress makes the following findings: 
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1 (1) There are hospitals throughout the United 

2 States that have inadequate staffing of registered 

3 nurses to protect the well-being and health of the 

4 patients. 

5 (2) Studies show that the health of patients in 

6 hospitals is directly proportionate to the number of 

7 registered nurses working in the hospital. 

8 (3) There is a critical shortage of registered 

9 nurses in the United States. 

10 (4) The effect of that shortage is revealed in 

11 unsafe staffing levels in hospitals. 

12 (5) Patient safety is adversely affected by these 

13 unsafe staffing levels, creating a public health crisis. 

14 (6) Registered nurses are being required to per15 form professional services under conditions that do 

16 not support quality health care or a healthful work 

17 environment for registered nurses. 

18 (7) As a payer for inpatient and outpatient hos19 pital services for individuals entitled to benefits 

20 under the program established under title XVIII of 

21 the Social Security Act, the Federal Government has 

22 a compelling interest in promoting the safety of such 

23 individuals by requiring any hospital participating in 

24 such program to establish minimum safe staffing 

25 levels for registered nurses. 
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1 SEC. 3. ESTABLISHMENT OF MINIMUM STAFFING RATIOS 

2 BY MEDICARE PARTICIPATING HOSPITALS. 

3 (a) REQUIREMENT OF MEDICARE PROVIDER AGREE4 MENT.—Section 1866(a)(1) of the Social Security Act (42 

5 U.S.C. 1395cc(a)(1)) is amended—

6 (1) by striking ‘‘and’’ at the end of subpara7 graph (U); 

8 (2) by striking the period at the end of sub9 paragraph (V) and inserting ‘‘, and’’; and 

10 (3) by inserting after subparagraph (V) and be11 fore the end matter the following: 

12 ‘‘(W) in the case of a hospital—

13 ‘‘(i) to adopt and implement a staffing 

14 system that meets the requirements of sec15 tion 1898; 

16 ‘‘(ii) to meet the requirements of such 

17 section relating to—

18 ‘‘(I) records maintenance; 

19 ‘‘(II) data collection; and 

20 ‘‘(III) data submission; and 

21 ‘‘(iii) to meet the requirements of 

22 such section relating to non-discrimination 

23 and retaliation.’’. 

24 (b) REQUIREMENTS.—Title XVIII of the Social Secu25 rity Act (42 U.S.C. 1395 et seq.) is amended by adding 

26 at the end the following: 
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1 ‘‘STAFFING REQUIREMENTS FOR MEDICARE

2 PARTICIPATING HOSPITALS

3 ‘‘SEC. 1898. (a) ESTABLISHMENT OF STAFFING SYS4 TEM.—Each participating hospital shall adopt and imple5 ment a staffing system that ensures a number of reg6 istered nurses on each shift and in each unit of the hos7 pital to ensure appropriate staffing levels for patient care. 

8 A staffing system adopted and implemented under this 

9 section shall—

10 ‘‘(1) be developed on the basis of input from 

11 the direct care-giving registered nurse staff or, 

12 where nurses are represented, with the applicable 

13 recognized or certified collective bargaining rep14 resentatives of the registered nurses; 

15 ‘‘(2) be based upon the number of patients and 

16 the level and variability of intensity of care to be 

17 provided, with appropriate consideration given to ad18 missions, discharges and transfers during each shift; 

19 ‘‘(3) account for contextual issues affecting 

20 staffing and the delivery of care, including architec21 ture and geography of the environment and available 

22 technology; 

23 ‘‘(4) reflect the level of preparation and experi24 ence of those providing care; 
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1 ‘‘(5) account for staffing level effectiveness or 

2 deficiencies in related health care classifications, in3 cluding but not limited to, certified nurse assistants, 

4 licensed vocational nurses, licensed psychiatric tech5 nicians, nursing assistants, aides and orderlies; 

6 ‘‘(6) reflect staffing levels recommended by spe7 cialty nursing organizations; 

8 ‘‘(7) subject to subsection (b), establish 

9 upwardly adjustable registered nurse-to-patient ra10 tios based upon registered nurses’ assessment of pa11 tient acuity and existing conditions; 

12 ‘‘(8) provide that a registered nurse shall not be 

13 assigned to work in a particular unit without first 

14 having established the ability to provide professional 

15 care in such unit; and 

16 ‘‘(9) be based on methods that assure validity 

17 and reliability. 

18 ‘‘(b) LIMITATION.—A staffing system adopted and 

19 implemented pursuant to subsection (a) may not—

20 ‘‘(1) set registered-nurse levels below those re21 quired by any Federal or State law or regulation; or 

22 ‘‘(2) utilize any minimum registered nurse-to23 patient ratio established pursuant to subsection 

24 (a)(7) as an upper limit on the staffing of the hos25 pital to which such ratio applies. 
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1 ‘‘(c) REPORTING, AND RELEASE TO PUBLIC, OF CER2 TAIN STAFFING INFORMATION.—

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

4 participating hospital shall—

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

6 visible place, a document that specifies in a uni7 form manner (as prescribed by the Secretary) 

8 the current number of licensed and unlicensed 

9 nursing staff directly responsible for patient 

10 care in each unit of the hospital, identifying 

11 specifically the number of registered nurses; 

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

13 public—

14 ‘‘(i) the nursing staff information de15 scribed in subparagraph (A); and 

16 ‘‘(ii) a detailed written description of 

17 the staffing system established by the hos18 pital pursuant to subsection (a); and 

19 ‘‘(C) submit to the Secretary in a uniform 

20 manner (as prescribed by the Secretary) the 

21 nursing staff information described in subpara22 graph (A) through electronic data submission 

23 not less frequently than quarterly. 

24 ‘‘(2) SECRETARIAL RESPONSIBILITIES.—The 

25 Secretary shall—
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1 ‘‘(A) make the information submitted pur2 suant to paragraph (1)(C) publicly available, in3 cluding by publication of such information on 

4 the Internet site of the Department of Health 

5 and Human Services; and 

6 ‘‘(B) provide for the auditing of such infor7 mation for accuracy as a part of the process of 

8 determining whether an institution is a hospital 

9 for purposes of this title. 

10 ‘‘(d) RECORD-KEEPING; DATA COLLECTION; EVAL11 UATION.—

12 ‘‘(1) RECORD-KEEPING.—Each participating 

13 hospital shall maintain for a period of at least 3 

14 years (or, if longer, until the conclusion of pending 

15 enforcement activities) such records as the Secretary 

16 deems necessary to determine to whether the hos17 pital has adopted and implemented a staffing system 

18 pursuant to subsection (a). 

19 ‘‘(2) DATA COLLECTION ON CERTAIN OUT20 COMES.—The Secretary shall require the collection, 

21 maintenance, and submission of data by each par22 ticipating hospital sufficient to establish the link be23 tween the staffing system established pursuant to 

24 subsection (a) and—
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1 ‘‘(A) patient acuity from maintenance of 

2 acuity data through entries on patients’ charts; 

3 ‘‘(B) patient outcomes that are nursing 

4 sensitive, such as patient falls, adverse drug 

5 events, injuries to patients, skin breakdown, 

6 pneumonia, infection rates, upper gastro7 intestinal bleeding, shock, cardiac arrest, length 

8 of stay, and patient re-admissions; 

9 ‘‘(C) operational outcomes, such as work10 related injury or illness, vacancy and turnover 

11 rates, nursing care hours per patient day, on12 call use, overtime rates, and needle-stick inju13 ries; and 

14 ‘‘(D) patient complaints related to staffing 

15 levels. 

16 ‘‘(3) EVALUATION.—Each participating hospital 

17 shall annually evaluate its staffing system and estab18 lished minimum registered nurse staffing ratios to 

19 assure on-going reliability and validity of the system 

20 and ratios. The evaluation shall be conducted by a 

21 joint management-staff committee comprised of at 

22 least 50 percent of registered nurses who provide di23 rect patient care and where nurses are represented, 

24 with the involvement of the applicable recognized or 
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1 certified collective bargaining representatives of the 

2 registered nurses. 

3 ‘‘(e) ENFORCEMENT.—

4 ‘‘(1) RESPONSIBILITY.—The Secretary shall en5 force the requirements and prohibitions of this sec6 tion. 

7 ‘‘(2) PROCEDURES FOR RECEIVING AND INVES8 TIGATING COMPLAINTS.—The Secretary shall estab9 lish procedures under which—

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

11 a participating hospital has violated a require12 ment or a prohibition of this section; and 

13 ‘‘(B) such complaints are investigated by 

14 the Secretary. 

15 ‘‘(3) REMEDIES.—If the Secretary determines 

16 that a participating hospital has violated a require17 ment of this section, the Secretary—

18 ‘‘(A) shall require the facility to establish 

19 a corrective action plan to prevent the recur20 rence of such violation; and 

21 ‘‘(B) may impose civil money penalties 

22 under paragraph (4). 

23 ‘‘(4) CIVIL MONEY PENALTIES.—

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

25 other penalties prescribed by law, the Secretary 
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1 may impose a civil money penalty of not more 

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

3 requirement of this section, except that the Sec4 retary shall impose a civil money penalty of 

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

6 the case of a participating hospital that the 

7 Secretary determines has a pattern or practice 

8 of such violations (with the amount of such ad9 ditional penalties being determined in accord10 ance with a schedule or methodology specified 

11 in regulations). 

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

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

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

15 this paragraph in the same manner as such 

16 provisions apply to a penalty or proceeding 

17 under section 1128A. 

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

19 ‘‘(i) INTERNET SITE.—The Secretary 

20 shall publish on the Internet site of the 

21 Department of Health and Human Serv22 ices the names of participating hospitals on 

23 which civil money penalties have been im24 posed under this section, the violation for 

25 which the penalty was imposed, and such 
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1 additional information as the Secretary de2 termines appropriate. 

3 ‘‘(ii) CHANGE OF OWNERSHIP.—With 

4 respect to a participating hospital that had 

5 a change in ownership, as determined by 

6 the Secretary, penalties imposed on the 

7 hospital while under previous ownership 

8 shall no longer be published by the Sec9 retary of such Internet site after the 1-

10 year period beginning on the date of 

11 change in ownership. 

12 ‘‘(f) WHISTLE-BLOWER PROTECTIONS.—

13 ‘‘(1) PROHIBITION OF DISCRIMINATION AND

14 RETALIATION.—A participating hospital shall not 

15 discriminate or retaliate in any manner against any 

16 patient or employee of the hospital because that pa17 tient or employee, or any other person, has pre18 sented a grievance or complaint, or has initiated or 

19 cooperated in any investigation or proceeding of any 

20 kind, relating to the staffing system or other re21 quirements and prohibitions of this section. 

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

23 An employee of a participating hospital who has 

24 been discriminated or retaliated against in employ25 ment in violation of this subsection may initiate judi-
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1 cial action in a United States District Court and 

2 shall be entitled to reinstatement, reimbursement for 

3 lost wages and work benefits caused by the unlawful 

4 acts of the employing hospital. Prevailing employees 

5 are entitled to reasonable attorney’s fees and costs 

6 associated with pursuing the case. 

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

8 patient who has been discriminated or retaliated 

9 against in violation of this subsection may initiate 

10 judicial action in a United States District Court. A 

11 prevailing patient shall be entitled to liquidated 

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

13 addition to any other damages under other applica14 ble statutes, regulations or common law. Prevailing 

15 patients are entitled to reasonable attorney’s fees 

16 and costs associated with pursuing the case. 

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

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

19 years after the discrimination or retaliation with re20 spect to which the action is brought. 

21 ‘‘(5) TREATMENT OF ADVERSE EMPLOYMENT

22 ACTIONS.—For purposes of this subsection—

23 ‘‘(A) an adverse employment action shall 

24 be treated as ‘retaliation or discrimination’; and 
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1 ‘‘(B) an adverse employment action in2 cludes—

3 ‘‘(i) the failure to promote an indi4 vidual or provide any other employment-re5 lated benefit for which the individual would 

6 otherwise be eligible; 

7 ‘‘(ii) an adverse evaluation or decision 

8 made in relation to accreditation, certifi9 cation, credentialing, or licensing of the in10 dividual; and 

11 ‘‘(iii) a personnel action that is ad12 verse to the individual concerned. 

13 ‘‘(g) RULES OF CONSTRUCTION.—

14 ‘‘(1) RELATIONSHIP TO STATE LAWS.—Nothing 

15 in this section shall be construed as exempting or re16 lieving any person from any liability, duty, penalty, 

17 or punishment provided by any present or future law 

18 of any State or political subdivision of a State, other 

19 than any such law which purports to require or per20 mit the doing of any act which would be an unlawful 

21 practice under this title. 

22 ‘‘(2) RELATIONSHIP TO CONDUCT PROHIBITED

23 UNDER THE NATIONAL LABOR RELATIONS ACT.—

24 Nothing in this section shall be construed as permit25 ting conduct prohibited under the National Labor 
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1 Relations Act or under any other federal, State, or 

2 local collective bargaining law. 

3 ‘‘(h) REGULATIONS.—The Secretary shall promul4 gate such regulations as are appropriate and necessary to 

5 implement this Act. 

6 ‘‘(i) DEFINITIONS.—For purposes of this section—

7 ‘‘(1) the term ‘participating hospital’ means a 

8 hospital that has entered into a provider agreement 

9 under section 1866; 

10 ‘‘(2) the term ‘registered nurse’ means an indi11 vidual who has been granted a license to practice as 

12 a registered nurse in at least one State; 

13 ‘‘(3) the term ‘unit’ of a hospital is an organi14 zational department or separate geographic area of 

15 a hospital, such as a burn unit, a labor and delivery 

16 room, a post-anesthesia service area, an emergency 

17 department, an operating room, a pediatric unit, a 

18 step-down or intermediate care unit, a specialty care 

19 unit, a telemetry unit, a general medical care unit, 

20 a subacute care unit, and a transitional inpatient 

21 care unit; 

22 ‘‘(4) a ‘shift’ is a scheduled set of hours or duty 

23 period to be worked at a participating hospital; and 
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1 ‘‘(5) a ‘person’ includes one or more individ2 uals, associations, corporations, unincorporated or3 ganizations or labor unions.’’. 

4 (c) EFFECTIVE DATE.—The amendments made by 

5 this section shall become effective on January 1, 2006.

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