II 

112TH CONGRESS 

1ST SESSION S. 58 

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 

JANUARY 25 (legislative day, JANUARY 5), 2011 

Mr. INOUYE 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 2011’’. 

6 SEC. 2. FINDINGS. 

7 Congress makes the following findings: 


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1 (1) There are a number of hospitals throughout 

2 the United States that do not provide adequate reg3 istered nurse staffing to protect the health and safe4 ty of patients. 

5 (2) Research shows that patient safety in hos6 pitals is directly proportionate to the number of reg7 istered nurses working in the hospital. Higher staff8 ing levels by experienced registered nurses are re9 lated to lower rates of negative patient outcomes, in10 cluding falls, infections, medication errors, and even 

11 death. 

12 (3) Inadequate nurse staffing was found to be 

13 a contributing factor in 24 percent of all unantici14 pated events that resulted in patient death, injury, 

15 or permanent loss of function. 

16 (4) Registered nurses play a vital role in pre17 venting patient care errors, for example registered 

18 nurses intercepted 86 percent of medical errors be19 fore those errors affected patients. 

20 (5) As a payer for inpatient and outpatient hos21 pital services for individuals entitled to benefits 

22 under the Medicare program, the Federal Govern23 ment has a compelling interest in promoting the 

24 safety of such individuals by requiring any hospital 


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1 participating in that program to establish minimum 

2 safe staffing levels for registered nurses. 

3 (6) Adequate registered nurse staffing levels are 

4 necessary for the delivery of safe, quality care. Inad5 equate registered nurse staffing levels contribute to 

6 nurse burnout and exacerbate the current nursing 

7 shortage in the United States. 

8 (7) Nearly 25 percent of registered nurses indi9 cate that they are considering leaving direct patient 

10 care nursing due to inadequate nurse staffing, and 

11 nearly 60 percent of registered nurses report they 

12 know of another nurse who left direct care nursing 

13 because of concerns about inadequate nurse staffing. 

14 (8) The cost to a hospital to replace a direct 

15 patient care registered nurse is more than 101 per16 cent, and as much as 106 percent, of a registered 

17 nurse’s annual salary. 

18 (9) As a result of insufficient staff, registered 

19 nurses are being required to perform professional 

20 services under conditions that do not support quality 

21 health care or a healthful work environment for reg22 istered nurses. 


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1 SEC. 3. ESTABLISHMENT OF SAFE NURSE STAFFING LEV2 ELS BY MEDICARE PARTICIPATING HOS3 PITALS. 

4 (a) REQUIREMENT OF MEDICARE PROVIDER AGREE5 MENT.—Section 1866(a)(1) of the Social Security Act (42 

6 U.S.C. 1395cc(a)(1)) is amended— 

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

8 the end; 

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

10 3005 of the Patient Protection and Affordable Care 

11 Act (Public Law 111–148)— 

12 (A) by moving such subparagraph 2 ems to 

13 the left; and 

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

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

16 6406(b) of the Patient Protection and Affordable 

17 Care Act (Public Law 111–148)— 

18 (A) by moving such subparagraph 2 ems to 

19 the left; 

20 (B) by redesignating such subparagraph as 

21 subparagraph (X); and 

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

23 inserting ‘‘, and’’; and 

24 (4) by inserting after subparagraph (X), as re25 designated by paragraph (3)(B), the following new 

26 subparagraph: 


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1 ‘‘(Y) in the case of a hospital (as defined in sec2 tion 1861(e)), to meet the requirements of section 

3 1899B.’’. 

4 (b) REQUIREMENTS.—Title XVIII of the Social Secu5 rity Act (42 U.S.C. 1395 et seq.) is amended by inserting 

6 after section 1899A the following new section: 

7 ‘‘NURSE STAFFING REQUIREMENTS FOR MEDICARE

8 PARTICIPATING HOSPITALS

9 ‘‘SEC. 1899B. (a) IMPLEMENTATION OF NURSE

10 STAFFING PLAN.— 

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

12 shall implement a hospital-wide staffing plan for 

13 nursing services furnished in the hospital. 

14 ‘‘(2) REQUIREMENT FOR DEVELOPMENT OF

15 STAFFING PLAN BY HOSPITAL NURSE STAFFING

16 COMMITTEE.—The hospital-wide staffing plan for 

17 nursing services implemented by a hospital pursuant 

18 to paragraph (1)— 

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

20 nurse staffing committee established under sub21 section (b); and 

22 ‘‘(B) shall require that an appropriate 

23 number of registered nurses provide direct pa24 tient care in each unit and on each shift of the 

25 hospital to ensure staffing levels that— 


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1 ‘‘(i) address the unique characteristics 

2 of the patients and hospital units; and 

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

4 quality patient care, consistent with the re5 quirements under subsection (c). 

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

7 ‘‘(1) ESTABLISHMENT.—Each participating 

8 hospital shall establish a hospital nurse staffing 

9 committee (hereinafter in this section referred to as 

10 the ‘Committee’). 

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

12 pursuant to this subsection shall be composed of 

13 members as follows: 

14 ‘‘(A) MINIMUM 55 PERCENT NURSE PAR15 TICIPATION.—Not less than 55 percent of the 

16 members of the Committee shall be registered 

17 nurses who provide direct patient care but who 

18 are neither hospital nurse managers nor part of 

19 the hospital administration staff. 

20 ‘‘(B) INCLUSION OF HOSPITAL NURSE

21 MANAGERS.—The Committee shall include 

22 members who are hospital nurse managers. 

23 ‘‘(C) INCLUSION OF NURSES FROM SPE24 CIALTY UNITS.—The members of the Com25 mittee shall include at least 1 registered nurse 


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1 who provides direct care from each nurse spe2 cialty or unit of the hospital (each such spe3 cialty or unit as determined by the hospital). 

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

5 Committee shall include such other personnel of 

6 the hospital as the hospital determines to be ap7 propriate. 

8 ‘‘(3) DUTIES.— 

9 ‘‘(A) DEVELOPMENT OF STAFFING

10 PLAN.—The Committee shall develop a hospital11 wide staffing plan for nursing services furnished 

12 in the hospital consistent with the requirements 

13 under subsection (c). 

14 ‘‘(B) REVIEW AND MODIFICATION OF

15 STAFFING PLAN.—The Committee shall— 

16 ‘‘(i) conduct regular, ongoing moni17 toring of the implementation of the hos18 pital-wide staffing plan for nursing services 

19 furnished in the hospital; 

20 ‘‘(ii) carry out evaluations of the hos21 pital-wide staffing plan for nursing services 

22 at least annually; and 

23 ‘‘(iii) make such modifications to the 

24 hospital-wide staffing plan for nursing 

25 services as may be appropriate. 


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1 ‘‘(C) ADDITIONAL DUTIES.—The Com2 mittee shall— 

3 ‘‘(i) develop policies and procedures 

4 for overtime requirements of registered 

5 nurses providing direct patient care and 

6 for appropriate time and manner of relief 

7 of such registered nurses during routine 

8 absences; and 

9 ‘‘(ii) carry out such additional duties 

10 as the Committee determines to be appro11 priate. 

12 ‘‘(c) STAFFING PLAN REQUIREMENTS.— 

13 ‘‘(1) PLAN REQUIREMENTS.—Subject to para14 graph (2), a hospital-wide staffing plan for nursing 

15 services developed and implemented under this sec16 tion shall— 

17 ‘‘(A) be based upon input from the reg18 istered nurse staff of the hospital who provide 

19 direct patient care or their exclusive representa20 tives, as well as the chief nurse executive; 

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

22 and the level and variability of intensity of care 

23 to be provided to those patients, with appro24 priate consideration given to admissions, dis25 charges, and transfers during each shift; 


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1 ‘‘(C) take into account contextual issues 

2 affecting nurse staffing and the delivery of care, 

3 including architecture and geography of the en4 vironment and available technology; 

5 ‘‘(D) take into account the level of edu6 cation, training, and experience of those reg7 istered nurses providing direct patient care; 

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

9 and services provided by other health care per10 sonnel associated with nursing care, such as 

11 certified nurse assistants, licensed vocational 

12 nurses, licensed psychiatric technicians, nursing 

13 assistants, aides, and orderlies; 

14 ‘‘(F) take into account staffing levels rec15 ommended by specialty nursing organizations; 

16 ‘‘(G) establish adjustable minimum num17 bers of registered nurses based upon an assess18 ment by registered nurses of the level and vari19 ability of intensity of care required by patients 

20 under existing conditions; 

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

22 level staffing, quality and patient outcome data, 

23 and national comparisons, as available; 

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

25 not be assigned to work in a particular unit of 


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1 the hospital without first having established the 

2 ability to provide professional care in such unit; 

3 and 

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

5 all requirements of the hospital-wide staffing 

6 plan for nursing services during a declared 

7 state of emergency (as defined in subsection 

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

9 to provide an exceptional level of emergency or 

10 other medical services. 

11 ‘‘(2) LIMITATION.—A staffing system developed 

12 and implemented 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 website 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 entity with a con12 tract 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 WEBSITE.—Subject to the succeeding 

10 provisions of this subparagraph, the Sec11 retary shall make the data submitted pur12 suant to subparagraph (A) publicly avail13 able, including by publication on the Hos14 pital Compare Internet website of the De15 partment of Health and Human Services. 

16 ‘‘(ii) COMPREHENSIBLE FORMAT.— 

17 Data made available to the public under 

18 clause (i) shall be presented in a clearly 

19 understandable format that permits con20 sumers of hospital services to make mean21 ingful comparisons among hospitals, in22 cluding concise explanations in plain 

23 English of how to interpret the data, of the 

24 difference in types of nursing staff, of the 

25 relationship between nurse staffing levels 


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1 and quality of care, and of how nurse 

2 staffing may vary based on patient case 

3 mix. 

4 ‘‘(iii) OPPORTUNITY TO CORRECT ER5 RORS.—The Secretary shall establish a 

6 process under which participating hospitals 

7 may review data submitted to the Sec8 retary pursuant to subparagraph (A) to 

9 correct errors, if any, contained in that 

10 data submission before making the data 

11 available to the public under clause (i). 

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

13 shall provide for the analysis of quality data col14 lected from participating hospitals under paragraph 

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

16 staffing plans for nursing services implemented pur17 suant to subsection (a) on— 

18 ‘‘(A) patient outcomes that are nursing 

19 sensitive (such as pressure ulcers, fall occur20 rence, falls resulting in injury, length of stay, 

21 and central line catheter infections); and 

22 ‘‘(B) nursing workforce safety and reten23 tion (including work-related injury, staff skill 

24 mix, nursing care hours per patient day, va25 cancy and voluntary turnover rates, overtime 


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1 rates, use of temporary agency personnel, and 

2 nurse satisfaction). 

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

4 to accept an assignment as a nurse in a participating hos5 pital, or in a unit of a participating hospital, if— 

6 ‘‘(1) the assignment is in violation of the hos7 pital-wide staffing plan for nursing services imple8 mented pursuant to subsection (a); or 

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

10 training, or experience to fulfill the assignment with11 out compromising the safety of any patient or jeop12 ardizing the license of the nurse. 

13 ‘‘(g) ENFORCEMENT.— 

14 ‘‘(1) RESPONSIBILITY.—The Secretary shall en15 force the requirements and prohibitions of this sec16 tion in accordance with the succeeding provisions of 

17 this subsection. 

18 ‘‘(2) PROCEDURES FOR RECEIVING AND INVES19 TIGATING COMPLAINTS.—The Secretary shall estab20 lish procedures under which— 

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

22 a participating hospital has violated a require23 ment of or a prohibition under this section; and 

24 ‘‘(B) such complaints are investigated by 

25 the Secretary. 


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1 ‘‘(3) REMEDIES.—Except as provided in para2 graph (5), if the Secretary determines that a partici3 pating hospital has violated a requirement of this 

4 section, the Secretary— 

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

6 a corrective action plan to prevent the recur7 rence of such violation; and 

8 ‘‘(B) may impose civil money penalties 

9 under paragraph (4). 

10 ‘‘(4) CIVIL MONEY PENALTIES.— 

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

12 other penalties prescribed by law, the Secretary 

13 may impose a civil money penalty of not more 

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

15 requirement of this section, except that the Sec16 retary shall impose a civil money penalty of 

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

18 the case of a participating hospital that the 

19 Secretary determines has a pattern or practice 

20 of such violations (with the amount of such ad21 ditional penalties being determined in accord22 ance with a schedule or methodology specified 

23 in regulations). 

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

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


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

2 this paragraph in the same manner as such 

3 provisions apply to a penalty or proceeding 

4 under section 1128A. 

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

6 ‘‘(i) INTERNET WEBSITE.—The Sec7 retary shall publish on an appropriate 

8 Internet website of the Department of 

9 Health and Human Services the names of 

10 participating hospitals on which civil 

11 money penalties have been imposed under 

12 this section, the violation for which the 

13 penalty was imposed, and such additional 

14 information as the Secretary determines 

15 appropriate. 

16 ‘‘(ii) CHANGE OF OWNERSHIP.—With 

17 respect to a participating hospital that had 

18 a change in ownership, as determined by 

19 the Secretary, penalties imposed on the 

20 hospital while under previous ownership 

21 shall no longer be published by the Sec22 retary on such Internet website after the 

23 1-year period beginning on the date of the 

24 change in ownership. 


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

2 REPORT QUALITY DATA ON NURSING SERVICES.— 

3 ‘‘(A) IN GENERAL.—In the case of a par4 ticipating hospital that fails to comply with re5 quirements under subsection (e)(2) to collect, 

6 aggregate, maintain, and report quality data re7 lating to nursing services furnished by the hos8 pital, instead of the remedies described in para9 graph (3), the provisions of subparagraph (B) 

10 shall apply with respect to each such failure of 

11 the participating hospital. 

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

13 by a participating hospital to comply with the 

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

15 each such failure shall be deemed to be a failure 

16 to submit data required under section 

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

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

19 1886(m)(5)(A), as the case may be, with re20 spect to the participating hospital involved for 

21 that year. 

22 ‘‘(h) WHISTLEBLOWER PROTECTIONS.— 

23 ‘‘(1) PROHIBITION OF DISCRIMINATION AND

24 RETALIATION.—A participating hospital shall not 

25 discriminate or retaliate in any manner against any 


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1 patient or employee of the hospital because that pa2 tient or employee, or any other person, has pre3 sented a grievance or complaint, or has initiated or 

4 cooperated in any investigation or proceeding of any 

5 kind, relating to— 

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

7 nursing services developed and implemented 

8 under this section; or 

9 ‘‘(B) any right, other requirement or pro10 hibition under this section, including a refusal 

11 to accept an assignment described in subsection 

12 (f). 

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

14 An employee of a participating hospital who has 

15 been discriminated or retaliated against in employ16 ment in violation of this subsection may initiate judi17 cial action in a United States district court and shall 

18 be entitled to reinstatement, reimbursement for lost 

19 wages, and work benefits caused by the unlawful 

20 acts of the employing hospital. Prevailing employees 

21 are entitled to reasonable attorney’s fees and costs 

22 associated with pursuing the case. 

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

24 patient who has been discriminated or retaliated 

25 against in violation of this subsection may initiate 


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1 judicial action in a United States district court. A 

2 prevailing patient shall be entitled to liquidated 

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

4 addition to any other damages under other applica5 ble statutes, regulations, or common law. Prevailing 

6 patients are entitled to reasonable attorney’s fees 

7 and costs associated with pursuing the case. 

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

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

10 years after the discrimination or retaliation with re11 spect to which the action is brought. 

12 ‘‘(5) TREATMENT OF ADVERSE EMPLOYMENT

13 ACTIONS.—For purposes of this subsection— 

14 ‘‘(A) an adverse employment action shall 

15 be treated as discrimination or retaliation; and 

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

17 includes— 

18 ‘‘(i) the failure to promote an indi19 vidual or provide any other employment-re20 lated benefit for which the individual would 

21 otherwise be eligible; 

22 ‘‘(ii) an adverse evaluation or decision 

23 made in relation to accreditation, certifi24 cation, credentialing, or licensing of the in25 dividual; and 


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1 ‘‘(iii) a personnel action that is ad2 verse to the individual concerned. 

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

4 this section shall be construed as exempting or relieving 

5 any person from any liability, duty, penalty, or punish6 ment provided by the law of any State or political subdivi7 sion of a State, other than any such law which purports 

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

9 ‘‘(j) RELATIONSHIP TO CONDUCT PROHIBITED

10 UNDER THE NATIONAL LABOR RELATIONS ACT OR

11 OTHER COLLECTIVE BARGAINING LAWS.—Nothing in 

12 this section shall be construed as— 

13 ‘‘(1) permitting conduct prohibited under the 

14 National Labor Relations Act or under any other 

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

16 ‘‘(2) preempting, limiting, or modifying a collec17 tive bargaining agreement entered into by a partici18 pating hospital. 

19 ‘‘(k) REGULATIONS.— 

20 ‘‘(1) IN GENERAL.—The Secretary shall pro21 mulgate such regulations as are appropriate and 

22 necessary to implement this section. 

23 ‘‘(2) IMPLEMENTATION.— 

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

25 subparagraph (B), as soon as practicable but 


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1 not later than 2 years after the date of the en2 actment of this section, a participating hospital 

3 shall have implemented a hospital-wide staffing 

4 plan for nursing services under this section. 

5 ‘‘(B) SPECIAL RULE FOR RURAL HOS6 PITALS.—In the case of a participating hospital 

7 located in a rural area (as defined in section 

8 1886(d)(2)(D)), such participating hospital 

9 shall have implemented a hospital-wide staffing 

10 plan for nursing services under this section as 

11 soon as practicable but not later than 4 years 

12 after the date of the enactment of this section. 

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

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

15 term ‘declared state of emergency’ means an offi16 cially designated state of emergency that has been 

17 declared by the Federal Government or the head of 

18 the appropriate State or local governmental agency 

19 having authority to declare that the State, county, 

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

21 but does not include a state of emergency that re22 sults from a labor dispute in the health care indus23 try or consistent understaffing. 

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

25 ‘participating hospital’ means a hospital (as defined 


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

2 agreement under section 1866. 

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

4 more individuals, associations, corporations, unincor5 porated organizations, or labor unions. 

6 ‘‘(4) REGISTERED NURSE.—The term ‘reg7 istered nurse’ means an individual who has been 

8 granted a license to practice as a registered nurse in 

9 at least 1 State. 

10 ‘‘(5) SHIFT.—The term ‘shift’ means a sched11 uled set of hours or duty period to be worked at a 

12 participating hospital. 

13 ‘‘(6) UNIT.—The term ‘unit’ means, with re14 spect to a hospital, an organizational department or 

15 separate geographic area of a hospital, including a 

16 burn unit, a labor and delivery room, a post-anes17 thesia service area, an emergency department, an 

18 operating room, a pediatric unit, a stepdown or in19 termediate care unit, a specialty care unit, a telem20 etry unit, a general medical care unit, a subacute 

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

Æ 


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