II 

111TH CONGRESS 

1ST SESSION S. 1031 

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 

MAY 13, 2009 

Mrs. BOXER 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. 

4 This Act may be cited as the ‘‘National Nursing 

5 Shortage Reform and Patient Advocacy Act’’. 

6 SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE 

7 STAFFING REQUIREMENTS. 

8 (a) MINIMUM DIRECT CARE REGISTERED NURSE

9 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 XXXI—MINIMUM DIRECT 

4 CARE REGISTERED NURSE 

5 STAFFING REQUIREMENTS 

6 ‘‘SEC. 3101. MINIMUM NURSE STAFFING REQUIREMENTS. 

7 ‘‘(a) STAFFING PLAN.— 

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

9 a staffing plan that— 

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

11 quality delivery of health care services and pro12 tects patient safety; and 

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

14 this title. 

15 ‘‘(2) EFFECTIVE DATES.— 

16 ‘‘(A) IMPLEMENTATION OF STAFFING

17 PLAN.—Subject to subparagraph (B), the re18 quirements under paragraph (1) shall take ef19 fect not later than 1 year after the date of en20 actment of this title. 

21 ‘‘(B) APPLICATION OF MINIMUM DIRECT

22 CARE REGISTERED NURSE-TO-PATIENT RA23 TIOS.—The requirements under subsection (b) 

24 shall take effect as soon as practicable, as de25 termined by the Secretary, but not later than 2 


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1 years after the date of enactment of this title, 

2 or in the case of a hospital in a rural area (as 

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

4 Security Act), not later than 4 years after the 

5 date of enactment of this title. 

6 ‘‘(b) MINIMUM DIRECT CARE REGISTERED NURSE7 TO-PATIENT RATIOS.— 

8 ‘‘(1) IN GENERAL.—Except as otherwise pro9 vided in this section, a hospital’s staffing plan shall 

10 provide that, at all times during each shift within a 

11 unit of the hospital, a direct care registered nurse 

12 shall be assigned to not more than the following 

13 number of patients in that unit, subject to para14 graph (4): 

15 ‘‘(A) 1 patient in trauma emergency units. 

16 ‘‘(B) 1 patient in operating room units, 

17 provided that a minimum of 1 additional person 

18 serves as a scrub assistant in such unit. 

19 ‘‘(C) 2 patients in critical care units, in20 cluding neonatal intensive care units, emer21 gency critical care and intensive care units, 

22 labor and delivery units, coronary care units, 

23 acute respiratory care units, postanesthesia 

24 units, and burn units. 


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1 ‘‘(D) 3 patients in emergency room units, 

2 stepdown units, pediatrics units, telemetry 

3 units, and combined labor, delivery, and 

4 postpartum units. 

5 ‘‘(E) 4 patients in antepartum units, inter6 mediate care nursery units, psychiatric units, 

7 and other specialty care units. 

8 ‘‘(F) 5 patients in medical-surgical units, 

9 rehabilitation units, and skilled nursing units. 

10 ‘‘(G) 8 patients in well-baby nursery units 

11 and postpartum (4 couplets) units. 

12 ‘‘(2) SIMILAR UNITS WITH DIFFERENT

13 NAMES.—The Secretary may apply minimum direct 

14 care registered nurse-to-patient ratios established in 

15 paragraph (1) to a type of hospital unit not referred 

16 to in such paragraph if such other unit performs a 

17 function similar to the function performed by the 

18 unit referred to in such paragraph. 

19 ‘‘(3) RESTRICTIONS.— 

20 ‘‘(A) PROHIBITION AGAINST AVERAGING.— 

21 A hospital shall not average the number of pa22 tients and the total number of direct care reg23 istered nurses assigned to patients in a hospital 

24 unit during any 1 shift or over any period of 


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1 time for purposes of meeting the requirements 

2 under this subsection. 

3 ‘‘(B) PROHIBITION AGAINST IMPOSITION

4 OF MANDATORY OVERTIME REQUIREMENTS.—A 

5 hospital shall not impose mandatory overtime 

6 requirements to meet the hospital unit direct 

7 care registered nurse-to-patient ratios required 

8 under this subsection. 

9 ‘‘(C) RELIEF DURING ROUTINE AB10 SENCES.—A hospital shall ensure that only a 

11 direct care registered nurse may relieve another 

12 direct care registered nurse during breaks, 

13 meals, and other routine, expected absences 

14 from a hospital unit. 

15 ‘‘(D) PROHIBITION AGAINST IMPOSITION

16 OF LAY-OFFS.—A hospital shall not impose lay17 offs of licensed vocational or practical nurses, 

18 licensed psychiatric technicians, certified nurs19 ing assistants, or other ancillary staff to meet 

20 the hospital unit direct care registered nurse-to21 patient ratios required under this subsection. 

22 ‘‘(4) ADJUSTMENT OF RATIOS.— 

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

24 patient safety, the Secretary may prescribe reg25 ulations that— 


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1 ‘‘(i) increase minimum direct care reg2 istered nurse-to-patient ratios under this 

3 subsection to further limit the number of 

4 patients that may be assigned to each di5 rect care nurse; or 

6 ‘‘(ii) add minimum direct care reg7 istered nurse-to-patient ratios for units not 

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

9 ‘‘(B) CONSULTATION.—Such regulations 

10 shall be prescribed after consultation with af11 fected hospitals and registered nurses. 

12 ‘‘(5) NO PREEMPTION OF CERTAIN STATE-IM13 POSED RATIOS.—Nothing in this title shall preempt 

14 State standards that the Secretary determines to be 

15 at least equivalent to Federal requirements for a 

16 staffing plan established under this title. Minimum 

17 direct care registered nurse-to-patient ratios estab18 lished under this subsection shall not preempt State 

19 requirements that the Secretary determines are at 

20 least equivalent to Federal requirements for a staff21 ing plan established under this title. 

22 ‘‘(6) EXEMPTION IN EMERGENCIES.—The re23 quirements established under this subsection shall 

24 not apply during a declared state of emergency if a 

25 hospital is requested or expected to provide an exVerDate Nov 24 2008 00:33 May 15, 2009 Jkt 079200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S1031.IS S1031

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1 ceptional level of emergency or other medical serv2 ices. 

3 ‘‘(c) DEVELOPMENT AND REEVALUATION OF STAFF4 ING PLAN.— 

5 ‘‘(1) CONSIDERATIONS IN DEVELOPMENT OF

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

7 shall provide for direct care registered nurse-to-pa8 tient ratios above the minimum direct care reg9 istered nurse-to-patient ratios required under sub10 section (b) if appropriate based upon consideration 

11 of the following factors: 

12 ‘‘(A) The number of patients and acuity 

13 level of patients as determined by the applica14 tion of an acuity system (as defined in section 

15 3107(1)), on a shift-by-shift basis. 

16 ‘‘(B) The anticipated admissions, dis17 charges, and transfers of patients during each 

18 shift that impacts direct patient care. 

19 ‘‘(C) Specialized experience required of di20 rect care registered nurses on a particular unit. 

21 ‘‘(D) Staffing levels and services provided 

22 by other health care personnel in meeting direct 

23 patient care needs not required by a direct care 

24 registered nurse. 


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1 ‘‘(E) The level of technology available that 

2 affects the delivery of direct patient care. 

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

4 practices, policies, and procedures by temporary 

5 agency direct care registered nurses used dur6 ing a shift. 

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

8 of patient care presented by physical layout. 

9 ‘‘(2) DOCUMENTATION OF STAFFING.—A hos10 pital shall specify the system used to document ac11 tual staffing in each unit for each shift. 

12 ‘‘(3) ANNUAL REEVALUATION OF PLAN AND

13 ACUITY SYSTEM.— 

14 ‘‘(A) IN GENERAL.—A hospital shall annu15 ally evaluate— 

16 ‘‘(i) its staffing plan in each unit in 

17 relation to actual patient care require18 ments; and 

19 ‘‘(ii) the accuracy of its acuity system. 

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

21 staffing plan and acuity system to the extent 

22 appropriate based on such evaluation. 

23 ‘‘(4) TRANSPARENCY.— 

24 ‘‘(A) IN GENERAL.—Any acuity-based pa25 tient classification system adopted by a hospital 


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1 under this section shall be transparent in all re2 spects, including disclosure of detailed docu3 mentation of the methodology used to predict 

4 nursing staffing, identifying each factor, as5 sumption, and value used in applying such 

6 methodology. 

7 ‘‘(B) PUBLIC AVAILABILITY.—The Sec8 retary shall establish procedures to provide that 

9 the documentation submitted under subsection 

10 (e) is available for public inspection in its en11 tirety. 

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

13 staffing plan of a hospital shall be developed and 

14 subsequent reevaluations shall be conducted under 

15 this subsection on the basis of input from direct care 

16 registered nurses at the hospital or, where such 

17 nurses are represented through collective bargaining, 

18 from the applicable recognized or certified collective 

19 bargaining representative of such nurses. Nothing in 

20 this title shall be construed to permit conduct pro21 hibited under the National Labor Relations Act or 

22 under the Federal Labor Relations Act. 

23 ‘‘(d) ACUITY TOOL.— 

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

25 after the date of enactment of the National Nursing 


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1 Shortage Reform and Patient Advocacy Act, the 

2 Secretary shall develop a national acuity tool that 

3 provides a method for establishing nurse staffing re4 quirements above the hospital unit direct care reg5 istered nurse-to-patient ratios required under sub6 section (b). 

7 ‘‘(2) IMPLEMENTATION.—Each hospital shall 

8 adopt and implement the national acuity tool de9 scribed in paragraph (1), and provide staffing based 

10 on such tool. Any additional direct care registered 

11 nursing staffing above the hospital unit direct care 

12 registered nurse-to-patient ratios described in sub13 section (b) shall be assigned in a manner determined 

14 by such national acuity tool. 

15 ‘‘(e) SUBMISSION OF PLAN TO SECRETARY.—A hos16 pital shall submit to the Secretary its staffing plan re17 quired under subsection (a)(1) and any annual updates 

18 under subsection (c)(3)(B). 

19 ‘‘SEC. 3102. POSTING, RECORDS, AND AUDITS. 

20 ‘‘(a) POSTING REQUIREMENTS.—In each unit, a hos21 pital shall post a uniform notice in a form specified by 

22 the Secretary in regulation that— 

23 ‘‘(1) explains requirements imposed under sec24 tion 3101; 


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1 ‘‘(2) includes actual direct care registered 

2 nurse-to-patient ratios during each shift; and 

3 ‘‘(3) is visible, conspicuous, and accessible to 

4 staff, patients, and the public. 

5 ‘‘(b) RECORDS.— 

6 ‘‘(1) MAINTENANCE OF RECORDS.—Each hos7 pital shall maintain accurate records of actual direct 

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

9 for each shift for no less than 2 years. Such records 

10 shall include— 

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

12 ‘‘(B) the identity and duty hours of each 

13 direct care registered nurse assigned to each 

14 patient in each unit in each shift; and 

15 ‘‘(C) a copy of each notice posted under 

16 subsection (a). 

17 ‘‘(2) AVAILABILITY OF RECORDS.—Each hos18 pital shall make its records maintained under para19 graph (1) available to— 

20 ‘‘(A) the Secretary; 

21 ‘‘(B) registered nurses and their collective 

22 bargaining representatives (if any); and 

23 ‘‘(C) the public under regulations estab24 lished by the Secretary, or in the case of a fed25 erally operated hospital, under section 552 of 


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1 title 5, United States Code (commonly known 

2 as the ‘Freedom of Information Act’). 

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

4 audits to ensure— 

5 ‘‘(1) implementation of the staffing plan in ac6 cordance with this title; and 

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

8 section. 

9 ‘‘SEC. 3103. MINIMUM DIRECT CARE LICENSED PRACTICAL 

10 NURSE STAFFING REQUIREMENTS. 

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

12 shall comply with minimum direct care licensed practical 

13 nurse staffing requirements that the Secretary establishes 

14 for units in hospitals. Such staffing requirements shall be 

15 established not later than 18 months after the date of en16 actment of this title, and shall be based on the study con17 ducted under subsection (b). 

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

19 of enactment of this title, the Secretary, acting through 

20 the Director of the Agency for Healthcare Research and 

21 Quality, shall complete a study of licensed practical nurse 

22 staffing and its effects on patient care in hospitals. The 

23 Director may contract with a qualified entity or organiza24 tion to carry out such study under this paragraph. The 

25 Director shall consult with licensed practical nurses and 


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1 organizations representing licensed practical nurses re2 garding the design and conduct of the study. 

3 ‘‘(c) APPLICATION OF REGISTERED NURSE PROVI4 SIONS TO LICENSED PRACTICAL NURSE STAFFING RE5 QUIREMENTS.—Paragraphs (2), (4), (5)(A), and (6) of 

6 section 3101(b), section 3101(c), and section 3102 shall 

7 apply to the establishment and application of direct care 

8 licensed practical nurse staffing requirements under this 

9 section in the same manner that they apply to the estab10 lishment and application of direct care registered nurse11 to-patient ratios under sections 3101 and 3102. 

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

13 section shall take effect as soon as practicable, as deter14 mined by the Secretary, but not later than 2 years after 

15 the date of enactment of this title, or in the case of a 

16 hospital in a rural area (as defined in section 

17 1886(d)(2)(D) of the Social Security Act), not later than 

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

19 ‘‘SEC. 3104. FEDERAL ASSISTANCE FOR THE PURCHASE OF 

20 SAFE PATIENT HANDLING EQUIPMENT. 

21 ‘‘(a) IN GENERAL.—The Secretary shall establish a 

22 grant program to provide financial assistance to cover 

23 some or all of the costs of purchasing safe patient han24 dling equipment required by the Federal safe patient han25 dling standard, developed under section 3 of the National 


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1 Nursing Shortage Reform and Patient Advocacy Act, for 

2 health care facilities, such as hospitals, nursing facilities, 

3 and outpatient facilities, that— 

4 ‘‘(1) require such equipment in order to comply 

5 with the standards established under section 3 of the 

6 National Nursing Shortage Reform and Patient Ad7 vocacy Act; and 

8 ‘‘(2) demonstrate the financial inability to oth9 erwise afford the purchase of such equipment. 

10 ‘‘(b) APPLICATION.—A health care facility desiring a 

11 grant under this section shall submit to the Secretary an 

12 application— 

13 ‘‘(1) in such form and manner as the Secretary 

14 shall specify; and 

15 ‘‘(2) demonstrating true financial need, accord16 ing to a standard established by the Secretary. 

17 ‘‘(c) AUTHORIZATION OF APPROPRIATIONS.—There 

18 are authorized to be appropriated to be used for grant 

19 awards under this section $50,000,000 for fiscal year 

20 2010, which shall remain available until expended. 

21 ‘‘SEC. 3105. WHISTLEBLOWER AND PATIENT PROTECTIONS. 

22 ‘‘(a) RECOGNITION OF DUTY AND RIGHT OF NURSES

23 TO ADVOCATE IN THE EXCLUSIVE INTEREST OF THE PA24 TIENT.—A nurse shall have the right to act as the pa25 tient’s advocate, as circumstances require, by— 


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1 ‘‘(1) initiating action to improve health care or 

2 to change decisions or activities which, in the profes3 sional judgment of the nurse, are against the inter4 ests and wishes of the patient; and 

5 ‘‘(2) giving the patient an opportunity to make 

6 informed decisions about health care before it is pro7 vided. 

8 ‘‘(b) REFUSAL OF ASSIGNMENT.—A nurse may 

9 refuse to accept an assignment as a nurse in a hospital 

10 if— 

11 ‘‘(1) the assignment would violate section 3101 

12 or 3103; or 

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

14 training, or experience to fulfill the assignment with15 out compromising the safety of any patient or jeop16 ardizing the license of the nurse. 

17 ‘‘(c) RETALIATION FOR REFUSAL OF ASSIGNMENT

18 BARRED.— 

19 ‘‘(1) NO DISCHARGE, DISCRIMINATION, OR RE20 TALIATION.—No hospital shall discharge, discrimi21 nate, or retaliate in any manner with respect to any 

22 aspect of employment (as defined in section 

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1 ment against a nurse based on the nurse’s refusal of 

2 a work assignment under subsection (b). 

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

4 shall file a complaint or a report against a nurse 

5 with the appropriate State professional disciplinary 

6 agency because of the nurse’s refusal of a work as7 signment described in subsection (b). 

8 ‘‘(d) CAUSE OF ACTION.—Any nurse who has been 

9 discharged, discriminated against, or retaliated against in 

10 violation of subsection (c)(1) or against whom a complaint 

11 has been filed in violation of subsection (c)(2) may bring 

12 a cause of action in a United States district court. A nurse 

13 who prevails on the cause of action shall be entitled to 

14 one or more of the following: 

15 ‘‘(1) Reinstatement. 

16 ‘‘(2) Reimbursement of lost wages, compensa17 tion, and benefits. 

18 ‘‘(3) Attorneys’ fees. 

19 ‘‘(4) Court costs. 

20 ‘‘(5) Other damages. 

21 ‘‘(e) COMPLAINT TO SECRETARY.— 

22 ‘‘(1) IN GENERAL.—A nurse, patient, or other 

23 individual may file a complaint with the Secretary 

24 against a hospital that violates the provisions of this 

25 title. For any complaint filed, the Secretary shall— 


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

2 ‘‘(B) determine whether a violation of this 

3 title as alleged in the complaint has occurred; 

4 and 

5 ‘‘(C) if such a violation has occurred, issue 

6 an order that the complaining nurse or indi7 vidual shall not suffer any retaliation described 

8 in subsection (c) or subsection (g). 

9 ‘‘(f) TOLL-FREE TELEPHONE NUMBER.— 

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

11 for the establishment of a toll-free telephone hotline 

12 to provide information regarding the requirements 

13 under section 3101 and to receive reports of viola14 tions of such section. 

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

16 provide each patient admitted to the hospital for in17 patient care with the hotline described in paragraph 

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

19 hotline may be used to report inadequate staffing or 

20 care. 

21 ‘‘(g) PROTECTION FOR REPORTING.— 

22 ‘‘(1) PROHIBITION ON RETALIATION OR DIS23 CRIMINATION.—A hospital shall not discriminate or 

24 retaliate in any manner against any patient, em25 ployee, or contract employee of the hospital, or any 


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

2 good faith, individually or in conjunction with an3 other person or persons, has presented a grievance 

4 or complaint, or has initiated or cooperated in any 

5 investigation or proceeding of any governmental en6 tity, regulatory agency, or private accreditation 

7 body, made a civil claim or demand, or filed an ac8 tion relating to the care, services, or conditions of 

9 the hospital or of any affiliated or related facilities. 

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

11 this subsection, an individual shall be deemed to be 

12 acting in good faith if the individual reasonably be13 lieves— 

14 ‘‘(A) the information reported or disclosed 

15 is true; and 

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

17 or may occur. 

18 ‘‘(h) PROHIBITION ON INTERFERENCE WITH

19 RIGHTS.— 

20 ‘‘(1) EXERCISE OF RIGHTS.—It shall be unlaw21 ful for any hospital to— 

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

23 exercise, or attempt to exercise, by any person 

24 of any right provided or protected under this 

25 title; or 


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1 ‘‘(B) coerce or intimidate any person re2 garding the exercise or attempt to exercise such 

3 right. 

4 ‘‘(2) OPPOSITION TO UNLAWFUL POLICIES OR

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

6 discriminate or retaliate against any person for op7 posing any hospital policy, practice, or actions which 

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

9 any provision of this title. 

10 ‘‘(3) PROHIBITION ON INTERFERENCE WITH

11 PROTECTED COMMUNICATIONS.—A hospital (or an 

12 individual representing a hospital) shall not make, 

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

14 practice which in any manner directly or indirectly 

15 prohibits, impedes, or discourages a direct care reg16 istered nurse from, or intimidates, coerces, or in17 duces a direct care registered nurse regarding, en18 gaging in free speech activities or disclosing informa19 tion as provided under this title. 

20 ‘‘(4) PROHIBITION ON INTERFERENCE WITH

21 COLLECTIVE ACTION.—A hospital (or an individual 

22 representing a hospital) shall not in any way inter23 fere with the rights of nurses to organize, bargain 

24 collectively, and engage in concerted activity under 


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1 section 7 of the National Labor Relations Act (29 

2 U.S.C. 157). 

3 ‘‘(i) NOTICE.—A hospital shall post in an appropriate 

4 location in each unit a conspicuous notice in a form speci5 fied by the Secretary that— 

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

7 other individuals under this section; 

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

9 or other individual may file a complaint with the 

10 Secretary against a hospital that violates the provi11 sions of this title; and 

12 ‘‘(3) provides instructions on how to file a com13 plaint under paragraph (2). 

14 ‘‘(j) EFFECTIVE DATES.— 

15 ‘‘(1) REFUSAL; RETALIATION; CAUSE OF AC16 TION.— 

17 ‘‘(A) IN GENERAL.—Subsections (b) 

18 through (d) shall apply to refusals occurring on 

19 or after the effective date of the provision to 

20 which the refusal relates. 

21 ‘‘(B) EXCEPTION.—Subsection (b)(2) shall 

22 not apply to refusals in any hospital before the 

23 requirements of section 3101(a) apply to that 

24 hospital. 


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1 ‘‘(2) PROTECTIONS FOR REPORTING.—Sub2 section (g)(1) shall apply to actions occurring on or 

3 after the effective date of the provision to which the 

4 violation relates, except that such subsection shall 

5 apply to initiation, cooperation, or participation in 

6 an investigation or proceeding on or after the date 

7 of enactment of this title. 

8 ‘‘(3) NOTICE.—Subsection (i) shall take effect 

9 18 months after the date of enactment of this title. 

10 ‘‘SEC. 3106. ENFORCEMENT. 

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

12 requirements and prohibitions of this title in accordance 

13 with this section. 

14 ‘‘(b) PROCEDURES FOR RECEIVING AND INVES15 TIGATING COMPLAINTS.—The Secretary shall establish 

16 procedures under which— 

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

18 that a hospital has violated a requirement or a pro19 hibition of this title; and 

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

21 the Secretary. 

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

23 hospital has violated a requirement of this title, the Sec24 retary— 


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1 ‘‘(1) shall require the facility to establish a cor2 rective action plan to prevent the recurrence of such 

3 violation; and 

4 ‘‘(2) may impose civil money penalties, as de5 scribed in subsection (d). 

6 ‘‘(d) CIVIL PENALTIES.— 

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

8 penalties prescribed by law, the Secretary may im9 pose civil penalties as follows: 

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

11 may impose on a hospital found to be in viola12 tion of this title, a civil money penalty of not 

13 more than $25,000 for each knowing violation 

14 of a requirement of this title, except that the 

15 Secretary shall impose a civil money penalty of 

16 more than $25,000 for each such violation in 

17 the case of a participating hospital that the 

18 Secretary determines has a pattern or practice 

19 of such violations (with the amount of such ad20 ditional penalties being determined in accord21 ance with a schedule or methodology specified 

22 in regulations). 

23 ‘‘(B) INDIVIDUAL LIABILITY.—The Sec24 retary may impose on an individual who— 


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

2 by the Secretary to have violated a require3 ment of this title; and 

4 ‘‘(ii) willfully violates this title, 

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

6 for each such violation. 

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

8 1128A of the Social Security Act (other than sub9 sections (a) and (b)) shall apply to a civil money 

10 penalty under this paragraph in the same manner as 

11 such provisions apply to a penalty or proceeding 

12 under such section 1128A. 

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

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

15 publish on the Internet website of the Department 

16 of Health and Human Services the names of partici17 pating hospitals on which civil money penalties have 

18 been imposed under this subsection, the violation for 

19 which such penalty was imposed, and such addi20 tional information as the Secretary determines ap21 propriate. 

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

23 a participating hospital that had a change in owner24 ship, as determined by the Secretary, penalties im25 posed on the hospital while under previous ownerVerDate Nov 24 2008 00:33 May 15, 2009 Jkt 079200 PO 00000 Frm 00023 Fmt 6652 Sfmt 6201 E:\BILLS\S1031.IS S1031

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1 ship shall no longer be published by the Secretary of 

2 such Internet website after the 1-year period begin3 ning on the date of change in ownership. 

4 ‘‘(f) OFFSET.—Funds collected by the Secretary 

5 under this paragraph shall be used to offset the costs of 

6 enforcing this title. 

7 ‘‘SEC. 3107. DEFINITIONS. 

8 ‘‘For purposes of this title: 

9 ‘‘(1) ACUITY SYSTEM.—The term ‘acuity sys10 tem’ means an established measurement tool that— 

11 ‘‘(A) predicts nursing care requirements 

12 for individual patients based on severity of pa13 tient illness, need for specialized equipment and 

14 technology, intensity of nursing interventions 

15 required, and the complexity of clinical nursing 

16 judgment needed to design, implement, and 

17 evaluate the patient’s nursing care plan; 

18 ‘‘(B) details the amount of nursing care 

19 needed, both in number of nurses and in skill 

20 mix of nursing personnel required, on a daily 

21 basis, for each patient in a nursing department 

22 or unit; 

23 ‘‘(C) takes into consideration the patient 

24 care services provided not only by registered 


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1 nurses but also by direct care licensed practical 

2 nurses and other health care personnel; and 

3 ‘‘(D) is stated in terms that can be readily 

4 used and understood by nurses. 

5 ‘‘(2) DIRECT CARE LICENSED PRACTICAL

6 NURSE.—The term ‘direct care licensed practical 

7 nurse’ means an individual who has been granted a 

8 license by at least 1 State to practice as a licensed 

9 practical nurse or a licensed vocational nurse and 

10 who provides bedside care for 1 or more patients. 

11 ‘‘(3) NURSE.—The term ‘nurse’ means any di12 rect care registered nurse or direct care licensed 

13 practical nurse (as the case may be), regardless of 

14 whether or not the nurse is an employee. 

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

16 term ‘direct care registered nurse’ means an indi17 vidual who has been granted a license by at least 1 

18 State to practice as a registered nurse and who pro19 vides bedside care for 1 or more patients. 

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

21 includes the provision of services under a contract or 

22 other arrangement. 

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

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


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1 Social Security Act and includes a long-term care 

2 hospital, as defined in section 1861(ccc) of such Act. 

3 ‘‘(7) STAFFING PLAN.—The term ‘staffing plan’ 

4 means a staffing plan required under section 3101. 

5 ‘‘(8) DECLARED STATE OF EMERGENCY.—The 

6 term ‘declared state of emergency’ means a state of 

7 emergency that is an unpredictable or unavoidable 

8 occurrence at an unscheduled or unpredictable inter9 val, relating to health care delivery and requiring 

10 immediate medical interventions and care, that has 

11 been declared by the Federal Government or the 

12 head of the appropriate State or local governmental 

13 agency having authority to declare that the State, 

14 county, municipality, or locality is in a state of 

15 emergency, but such term does not include a state 

16 of emergency that results from a labor dispute in the 

17 health care industry or consistent understaffing. 

18 ‘‘SEC. 3108. RULE OF CONSTRUCTION. 

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

20 disclosure of private and confidential patient information, 

21 except in the case where such disclosure is otherwise re22 quired by law, compelled by proper legal process, con23 sented to by the patient, provided in confidence to regu24 latory or accreditation agencies or other government enti25 ties for investigatory purposes, or provided pursuant to 


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1 formal or informal complaints of unlawful or improper 

2 practices for purposes of achieving corrective and remedial 

3 action.’’. 

4 (b) RECOMMENDATIONS TO CONGRESS.—Not later 

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

6 Secretary of Health and Human Services shall submit to 

7 Congress a report containing recommendations for ensur8 ing that sufficient numbers of nurses are available to meet 

9 the requirements imposed by title XXXI of the Public 

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

11 SEC. 3. FEDERAL SAFE PATIENT HANDLING STANDARD. 

12 (a) IN GENERAL.—Not later than 1 year after the 

13 date of enactment of this Act, the Secretary of Labor, act14 ing through the Director of Occupational Safety and 

15 Health Administration, shall establish a Federal Safe Pa16 tient Handling Standard, consistent with section 6 of the 

17 Occupational Safety and Health Act of 1970 (29 U.S.C. 

18 655) to prevent musculoskeletal disorders for direct care 

19 registered nurses and other health care providers working 

20 in health care facilities. 

21 (b) DEVELOPMENT OF STANDARD.—In developing 

22 the standard under subsection (a), the Secretary shall so23 licit input from direct care registered nurses and organiza24 tions representing direct care registered nurses in imple25 menting the standard. 


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1 (c) REQUIREMENTS.—The standard promulgated 

2 under subsection (a) shall include— 

3 (1) a zero lift policy; 

4 (2) a musculoskeletal injury prevention plan, 

5 which shall include hazard identification and risk as6 sessments in relation to patient care duties and pa7 tient handling; 

8 (3) a program to identify problems and solu9 tions regarding safe patient handling; 

10 (4) a system to report, track, and analyze 

11 trends in injuries, as well as make injury data avail12 able to the public; 

13 (5) training for staff, including interactive 

14 classroom-based and hands-on training by a knowl15 edgeable person or staff, on safe patient handling 

16 policies, equipment, and devices at least on an an17 nual basis, which shall include training on hazard 

18 identification, assessment, and control of musculo19 skeletal hazards in patient care areas; and 

20 (6) annual evaluations of safe patient handling 

21 efforts, as well as new technology, handling proce22 dures, and engineering controls. 

23 (d) COMPLIANCE WITH THE STANDARD.—The Sec24 retary of Labor shall require— 


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1 (1) all health care facilities to comply with the 

2 standard developed under subsection (a); and 

3 (2) health care facilities to purchase, use, and 

4 maintain safe lift mechanical devices. 

5 (e) SAFE PATIENT HANDLING PLAN.—In accordance 

6 with the standard developed under subsection (a), and not 

7 later than 180 days after such standard is published, 

8 health care facilities shall develop and implement a safe 

9 patient handling plan that— 

10 (1) provides adequate, appropriate, and quality 

11 delivery of health care services that protects patient 

12 safety and prevents musculoskeletal disorders for di13 rect care registered nurses and other health care 

14 providers; 

15 (2) is consistent with the requirements of the 

16 Federal Safe Patient Handling Standard; 

17 (3) provides for input by direct care registered 

18 nurses and organizations representing direct care 

19 registered nurses in implementing the plan; and 

20 (4) ensures that safe lifting mechanical devices 

21 shall only be used by direct care registered nurses 

22 and other health care providers. 

23 (f) DEFINITIONS.—In this section— 

24 (1) the term ‘‘lift team’’ means employees of a 

25 hospital who are specially trained to handle patient 


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1 lifts, repositions, and transfers using patient trans2 fer devices or lifting devices as appropriate for the 

3 specific patient, based on a needs assessment of the 

4 individual hospital employer; and 

5 (2) the term ‘‘zero lift policy’’ means replacing 

6 unassisted manual lifting, repositioning, and trans7 ferring of patients with the use of patient transfer 

8 devices, lifting devices, and lift teams. Such term 

9 does not require the use of patient transfer or lifting 

10 devices when the lift, reposition, and transfer needs 

11 assessment indicates it is safe for the patient and 

12 the employee to use manual lifting, repositioning, 

13 and transferring techniques. 

14 SEC. 4. PAYMENT ADJUSTMENT FOR HOSPITALS UNDER 

15 THE MEDICARE PROGRAM BASED ON ADDI16 TIONAL COSTS OF COMPLYING WITH CER17 TAIN REQUIREMENTS. 

18 Section 1886 of the Social Security Act (42 U.S.C. 

19 1395ww), as amended by section 4102 of the HITECH 

20 Act (Public Law 111–5), is amended by adding at the end 

21 the following new subsection: 

22 ‘‘(o) ADJUSTMENT BASED ON ADDITIONAL COSTS OF

23 COMPLYING WITH CERTAIN REQUIREMENTS.— 

24 ‘‘(1) IN GENERAL.—With respect to inpatient 

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1 pital during a fiscal year (beginning with fiscal year 

2 2010), in addition to the amount otherwise paid 

3 under this section, there shall also be paid to the 

4 subsection (d) hospital, from the Federal Hospital 

5 Insurance Trust Fund established under section 

6 1817, an amount equal to the applicable amount 

7 specified in paragraph (2) for the subsection (d) hos8 pital for the fiscal year. 

9 ‘‘(2) APPLICABLE AMOUNT.—The applicable 

10 amount specified in this paragraph for a subsection 

11 (d) hospital for a fiscal year is equal to the quotient 

12 of— 

13 ‘‘(A) the total amount of additional costs 

14 incurred by the hospital in providing inpatient 

15 hospital services to beneficiaries during the fis16 cal year that are attributable to compliance 

17 with the requirements under sections 3101, 

18 3102, and 3103 of the Public Health Services 

19 Act (as estimated by the Secretary, taking into 

20 account recommendations contained in the re21 port under paragraph (3)); and 

22 ‘‘(B) the total number of discharges during 

23 the fiscal year (as estimated by the Secretary). 

24 ‘‘(3) MEDICARE PAYMENT ADVISORY COMMIS25 SION REPORT.—Not later than 2 years after the 


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1 date of the enactment of this subsection, the Medi2 care Payment Advisory Commission shall submit to 

3 Congress and the Secretary a report containing an 

4 estimate of the total costs to and savings for sub5 section (d) hospitals during a fiscal year that are at6 tributable to compliance with the requirements 

7 under sections 3101, 3102, and 3103 of the Public 

8 Health Service Act, including recommendations re9 garding the adjustment in payments to such hos10 pitals under this subsection, together with rec11 ommendations for such legislation and administra12 tive action as the Commission determines appro13 priate.’’. 

14 SEC. 5. ENFORCEMENT OF REQUIREMENTS THROUGH FED15 ERAL PROGRAMS. 

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

17 Social Security Act (42 U.S.C. 1395cc(a)(1)) is amend18 ed— 

19 (1) by striking ‘‘and’’ at the end of subpara20 graph (U); 

21 (2) by striking the period at the end of sub22 paragraph (V) and inserting ‘‘, and’’; and 

23 (3) by inserting after subparagraph (V) the fol24 lowing: 


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1 ‘‘(W) in the case of a hospital, to be subject to 

2 the provisions of title XXXI of the Public Health 

3 Service Act.’’. 

4 (b) MEDICAID PROGRAM.—The first sentence of sec5 tion 1902(a) of the Social Security Act (42 U.S.C. 

6 1396(a)), as amended by section 5006(e)(2)(A) of Divi7 sion B of the American Recovery and Reinvestment Act 

8 of 2009 (Public Law 111–5), is amended— 

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

10 (72); 

11 (2) by striking the period at the end of para12 graph (73) and inserting ‘‘; and’’; and 

13 (3) by inserting after paragraph (73) the fol14 lowing new paragraph: 

15 ‘‘(74) provide that any hospital receiving pay16 ments under such plan shall be subject to the provi17 sions of title XXXI of the Public Health Service 

18 Act.’’. 

19 SEC. 6. REGISTERED NURSE WORKFORCE INITIATIVE. 

20 Title VIII of the Public Health Service Act (42 

21 U.S.C. 296 et seq.) is amended by adding at the end the 

22 following: 


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1 ‘‘PART J—REGISTERED NURSE WORKFORCE 

2 INITIATIVE 

3 ‘‘SEC. 860. REGISTERED NURSE WORKFORCE INITIATIVE. 

4 ‘‘(a) ESTABLISHMENT.—The Secretary, acting 

5 through the Administrator of the Health Resources and 

6 Services Administration, shall carry out a Registered 

7 Nurse Workforce Initiative (referred to in this part as the 

8 ‘RNWI’) to ensure that there is an adequate number of 

9 registered nurses and to reduce critical workforce short10 ages in hospitals. 

11 ‘‘(b) PURPOSES.—The purposes of the RNWI are 

12 to— 

13 ‘‘(1) achieve short-term mitigation and remedy 

14 of the nationwide nursing shortage; and 

15 ‘‘(2) establish and maintain the necessary edu16 cational system foundations and institutional in17 volvement to ensure sufficient labor supply and labor 

18 market stability essential to ensuring safe and com19 petent hospital nursing care on an ongoing basis. 

20 ‘‘(c) DURATION.—The RNWI is established as a 5- 

21 year program for the purpose of adding new registered 

22 nurses to the workforce, and may be extended beyond the 

23 initial 5-year period, if the Secretary determines appro24 priate. 


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1 ‘‘SEC. 861. EDUCATIONAL ASSISTANCE BENEFITS. 

2 ‘‘(a) GRANTS FOR ASSOCIATE AND BACCALAUREATE

3 DEGREE PROGRAMS.— 

4 ‘‘(1) BASIC EDUCATIONAL ASSISTANCE BENE5 FITS.—To address the critical shortage of direct 

6 care registered nurses, the Secretary shall establish 

7 a nursing educational assistance grant program for 

8 eligible individuals who are accepted to, or are en9 rolled in, associate and baccalaureate degrees in 

10 nursing programs, based on such individuals’ finan11 cial need, as determined by the Secretary. 

12 ‘‘(2) SUPPLEMENTAL EDUCATIONAL ASSIST13 ANCE BENEFIT.— 

14 ‘‘(A) BENEFITS.—Each individual awarded 

15 a grant under this subsection shall receive— 

16 ‘‘(i) nursing educational assistance to 

17 help meet, in part, the annual expenses of 

18 enrolling in and attending an associate or 

19 a baccalaureate degree in nursing program; 

20 and 

21 ‘‘(ii) a monthly living stipend to help 

22 meet the individual’s basic living expenses. 

23 ‘‘(B) GRANT AMOUNTS.—The Secretary 

24 shall determine the amounts awarded under 

25 subparagraph (A) for each fiscal year, based 


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1 upon the cost of living and the cost of attending 

2 a nursing program for such fiscal year. 

3 ‘‘(3) ELIGIBILITY.—An individual desiring a 

4 grant under this subsection shall— 

5 ‘‘(A) be an individual who has been accept6 ed to an accredited nursing education program; 

7 ‘‘(B) provide assurances that such indi8 vidual will work for a health care provider that 

9 is eligible to receive national health service 

10 corps professionals for a period of not less than 

11 3 years, in a setting that the Secretary deter12 mines appropriate; and 

13 ‘‘(C) submit to the Secretary an applica14 tion at such time, in such manner, and con15 taining such information as the Secretary may 

16 require. 

17 ‘‘(b) GRANTS FOR ADVANCE DEGREES IN NURS18 ING.— 

19 ‘‘(1) IN GENERAL.—To address the critical 

20 shortage of nurse educators holding master’s or doc21 toral degrees in nursing, as well as the lack of mas22 ter’s and doctoral nursing students, the Secretary 

23 shall establish a program to award grants to eligible 

24 individuals to assist such individuals in pursuing 

25 graduate nursing degrees. 


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1 ‘‘(2) ELIGIBLE INDIVIDUALS.—An individual 

2 desiring a grant under this section shall— 

3 ‘‘(A) hold an unencumbered license as a 

4 registered nurse; 

5 ‘‘(B) be accepted into an accredited mas6 ter’s or doctorate degree program in nursing; 

7 ‘‘(C) provide assurances that such indi8 vidual will work as a nurse educator at an ac9 credited nursing program for a period of 5 

10 years after graduating from an accredited grad11 uate degree program in nursing; and 

12 ‘‘(D) submit to the Secretary an applica13 tion at such time, in such manner, and con14 taining such information as the Secretary may 

15 require. 

16 ‘‘(c) REPAYMENT OBLIGATION.—A recipient of a 

17 grant under this section who fails to meet the require18 ments of the grant, as described in this section or as speci19 fied by the Secretary, shall repay the Secretary all 

20 amounts received through such grant, with interest. 

21 ‘‘SEC. 862. PRECEPTORSHIP AND MENTORSHIP DEM22 ONSTRATION PROJECTS. 

23 ‘‘(a) IN GENERAL.—The Secretary shall award 

24 grants to eligible entities for the purpose of conducting 

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1 tion projects, designed to address nurse workforce short2 ages and improve patient care by providing additional sup3 port to nurses entering the workforce to promote the re4 tention of nurses in the workforce. 

5 ‘‘(b) ELIGIBLE ENTITIES.—An entity desiring a 

6 grant under this section shall— 

7 ‘‘(1) be a hospital; and 

8 ‘‘(2) submit an application to the Secretary at 

9 such time, in such manner, and containing such in10 formation as the Secretary may require. 

11 ‘‘(c) PRIORITY.—In awarding grants under this sec12 tion, the Secretary shall give priority to hospitals that 

13 have a critical shortage of nurses, as determined by the 

14 Secretary. 

15 ‘‘(d) PRECEPTORSHIP PROGRAM.— 

16 ‘‘(1) IN GENERAL.—The preceptorship program 

17 shall provide— 

18 ‘‘(A) a period of practical experience and 

19 training for nursing students, by providing clin20 ical supervision by a direct care registered 

21 nurse expert or specialist in a particular field; 

22 or 

23 ‘‘(B) a period of orientation for newly24 graduated or newly hired direct care registered 

25 nurses. 


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1 ‘‘(2) PURPOSE.—The purpose of the preceptor2 ship program is to establish a period of practical and 

3 clinical experiences and training for nursing stu4 dents, newly hired nurses and recent graduates of a 

5 direct care degree program for registered nurses. 

6 ‘‘(e) MENTORSHIP PROGRAM.— 

7 ‘‘(1) IN GENERAL.—The mentorship program 

8 shall match newly hired direct care registered nurses 

9 (referred to in this subsection as the ‘mentees’) with 

10 experienced direct care registered nurses, who shall 

11 serve as advocates and role models and help the 

12 mentees grow professionally, feel supported, and 

13 adapt to the culture of the acute care hospital. Men14 tors shall provide personal and career support in the 

15 workplace. 

16 ‘‘(2) PURPOSE.—The purpose of the mentorship 

17 program is to assist new or transitional direct care 

18 registered nurses to succeed in making their own 

19 contributions to the care of patients and to the nurs20 ing profession. 

21 ‘‘(f) REPORT.—Each recipient of a grant under this 

22 section, at the end of such recipient’s 5-year demonstra23 tion project, shall submit to the Secretary a report con24 taining an evaluation of the effect of the demonstration 


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1 project on nurse retention and patient care in the hospital 

2 for which such grant was awarded. 

3 ‘‘SEC. 863. AUTHORIZATION OF APPROPRIATIONS. 

4 ‘‘To carry out this part, there are authorized to be 

5 appropriated such funds as may be necessary for fiscal 

6 years 2010 through 2014.’’. 

Æ 


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