II 

110TH CONGRESS 

1ST SESSION S. 1842 

To amend title XVIII of the Social Security Act to provide for patient 

protection by limiting the number of mandatory overtime hours a nurse 

may be required to work in certain providers of services to which payments are made under the Medicare Program. 

IN THE SENATE OF THE UNITED STATES 

JULY 20, 2007 

Mr. KENNEDY (for himself, Mr. KERRY, Mr. DODD, Ms. MIKULSKI, Mrs. 

CLINTON, Mr. OBAMA, Mr. SANDERS, Mr. INOUYE, Mr. LEVIN, Mr. 

AKAKA, Mr. FEINGOLD, Ms. CANTWELL, Mr. MENENDEZ, and Mr. 

WHITEHOUSE) 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 limiting the number of mandatory overtime hours a nurse may be required to work 

in certain providers of services to which payments are 

made under the Medicare Program. 

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 ‘‘Safe Nursing and Pa5 tient Care Act of 2007’’. 


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1 SEC. 2. FINDINGS. 

2 Congress finds as follows: 

3 (1) The Federal Government has a substantial 

4 interest in assuring that the delivery of health care 

5 services to patients in health care facilities is ade6 quate and safe. 

7 (2) Research, including a study published in the 

8 Journal of the American Medical Association (in the 

9 October 23–30, 2002 issue), documents that higher 

10 nurse staffing levels result in better patient out11 comes. However, health care facilities report sub12 stantial difficulties in recruiting and retaining suffi13 cient nursing staff, as evidenced by the fact that ap14 proximately 500,000 licensed nurses are not prac15 ticing nursing. 

16 (3) Job dissatisfaction and overtime work are 

17 contributing to the departure of nurses from their 

18 profession, as documented by the Government Ac19 countability Office in a July 2001 report. Yet, health 

20 care providers continue to make use of mandatory 

21 overtime as a staffing model. 

22 (4) The widespread practice of requiring nurses 

23 to work extended shifts and forgo days off frequently 

24 causes nurses to provide care in a state of fatigue 

25 which contributes to medical errors and results in 

26 other consequences that compromise patient safety. 


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1 (5) The dangers with mandatory overtime are 

2 made clear by numerous studies. A November 2003 

3 Institute of Medicine report, entitled ‘‘Keeping Pa4 tients Safe: Transforming the Work Environment of 

5 Nurses’’, concluded that limiting the number of 

6 hours worked per day and consecutive days of work 

7 by nursing staff, as is done in other safety-sensitive 

8 industries, is a fundamental safety precaution. The 

9 report went on to specifically recommend that work10 ing more than 12 hours in any 24-hour period and 

11 more than 60 hours in any 7-day period be pre12 vented except in case of an emergency, such as a 

13 natural disaster. 

14 (6) Another study published in the July/August 

15 2004 Health Affairs Journal, entitled ‘‘The Working 

16 Hours of Hospital Staff Nurses and Patient Safe17 ty’’, found that nurses who worked shifts of twelve 

18 and a half hours or more were three times more like19 ly to commit an error than nurses who worked 

20 standard shifts of eight and a half hours or less. The 

21 study also found that working overtime increased 

22 the odds of making at least one error, regardless of 

23 how long the shift was originally scheduled. 

24 (7) The continuing research on the effects of 

25 mandatory overtime reinforces these findings. A 


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1 study published in the June 2007 issue of Medical 

2 Care, entitled ‘‘Nurse Working Conditions and Pa3 tient Safety Outcomes’’, found that patients in in4 tensive care units were more likely to suffer from 

5 hospital-related infection the more overtime their 

6 nurses worked. The study concluded that improving 

7 nurse working conditions would promote patient 

8 safety. 

9 (8) The 2004 Health Affairs Journal study de10 scribed in paragraph (6) also illustrates how nurses 

11 are being forced to work more and more overtime. 

12 The majority of nurses surveyed reported working 

13 overtime ten or more times in a twenty-eight day pe14 riod and one-sixth reported working sixteen or more 

15 consecutive hours at least once during the period. 

16 Nurses reported being mandated to work overtime 

17 on 360 shifts and on another 143 shifts they de18 scribed being ‘‘coerced’’ into working voluntary over19 time. 

20 (9) While no Federal standards currently re21 strict mandatory nurse overtime, many States are 

22 considering such laws and several States, including 

23 California, Connecticut, Illinois, Maine, Maryland, 

24 Minnesota, New Jersey, Oregon, Texas, Washington, 


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1 and West Virginia, have enacted laws or prescribed 

2 regulations. 

3 (10) Federal limitations on mandatory nurse 

4 overtime will ensure that health care facilities 

5 throughout the United States operate in a manner 

6 that safeguards public safety by helping assure the 

7 delivery of quality nursing care and facilitating the 

8 retention and recruitment of nurses. 

9 SEC. 3. LIMITATIONS ON MANDATORY OVERTIME FOR 

10 NURSES. 

11 (a) PROVIDER AGREEMENTS.—Section 1866 of the 

12 Social Security Act (42 U.S.C. 1395cc) is amended— 

13 (1) in subsection (a)(1)— 

14 (A) in subparagraph (U), by striking 

15 ‘‘and’’ at the end; 

16 (B) in subparagraph (V), by striking the 

17 period and inserting ‘‘, and’’; and 

18 (C) by inserting after subparagraph (V) 

19 the following new subparagraph: 

20 ‘‘(W) to comply with the requirements of 

21 subsection (k) (relating to limitations on man22 datory overtime for nurses).’’; and 

23 (2) by adding at the end the following new sub24 section: 


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1 ‘‘(k) LIMITATIONS ON MANDATORY OVERTIME FOR

2 NURSES.—For purposes of subsection (a)(1)(W), the re3 quirements of this subsection are the following: 

4 ‘‘(1) PROHIBITION ON MANDATORY OVER5 TIME.—Except as provided in this subsection, a pro6 vider of services shall not, directly or indirectly, re7 quire a nurse to work in excess of any of the fol8 lowing: 

9 ‘‘(A) The scheduled work shift or duty pe10 riod of the nurse. 

11 ‘‘(B) 12 hours in a 24-hour period. 

12 ‘‘(C) 80 hours in a consecutive 14-day pe13 riod. 

14 ‘‘(2) EXCEPTIONS.— 

15 ‘‘(A) IN GENERAL.—Subject to subpara16 graph (B), the requirements of paragraph (1) 

17 shall not apply to a provider of services during 

18 a declared state of emergency if the provider is 

19 requested, or otherwise is expected, to provide 

20 an exceptional level of emergency or other med21 ical services to the community. 

22 ‘‘(B) LIMITATIONS.—With respect to a 

23 provider of services to which subparagraph (A) 

24 applies, a nurse may only be required to work 


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1 for periods in excess of the periods described in 

2 paragraph (1) if— 

3 ‘‘(i) the provider has made reasonable 

4 efforts to fill the immediate staffing needs 

5 of the provider through alternative means; 

6 and 

7 ‘‘(ii) the duration of the work require8 ment does not extend past the earlier of— 

9 ‘‘(I) the date on which the de10 clared state of emergency ends; or 

11 ‘‘(II) the date on which the pro12 vider’s direct role in responding to the 

13 medical needs resulting from the de14 clared state of emergency ends. 

15 ‘‘(3) REPORT OF VIOLATIONS.— 

16 ‘‘(A) RIGHT TO REPORT.— 

17 ‘‘(i) IN GENERAL.—A nurse may file a 

18 complaint with the Secretary against a 

19 provider of services who violates the provi20 sions of this subsection. 

21 ‘‘(ii) PROCEDURE.—The Secretary 

22 shall establish a procedure under which a 

23 nurse may file a complaint under clause 

24 (i). 


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1 ‘‘(B) INVESTIGATION OF COMPLAINT.— 

2 The Secretary shall investigate complaints of 

3 violations filed by a nurse under subparagraph 

4 (A). 

5 ‘‘(C) ACTIONS.—If the Secretary deter6 mines that a provider of services has violated 

7 the provisions of this subsection, the Secretary 

8 shall require the provider to establish a plan of 

9 action to eliminate the occurrence of such viola10 tion, and may seek civil money penalties under 

11 paragraph (7). 

12 ‘‘(4) NURSE NONDISCRIMINATION PROTEC13 TIONS.— 

14 ‘‘(A) IN GENERAL.—A provider of services 

15 shall not penalize, discriminate, or retaliate in 

16 any manner with respect to any aspect of em17 ployment, including discharge, promotion, com18 pensation, or terms, conditions, or privileges of 

19 employment, against a nurse who refuses to 

20 work mandatory overtime or who in good faith, 

21 individually or in conjunction with another per22 son or persons— 

23 ‘‘(i) reports a violation or suspected 

24 violation of this subsection to a public reg25 ulatory agency, a private accreditation 


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1 body, or the management personnel of the 

2 provider of services; 

3 ‘‘(ii) initiates, cooperates, or otherwise 

4 participates in an investigation or pro5 ceeding brought by a regulatory agency or 

6 private accreditation body concerning mat7 ters covered by this subsection; or 

8 ‘‘(iii) informs or discusses with other 

9 employees, with representatives of those 

10 employees, or with representatives of asso11 ciations of health care professionals, viola12 tions or suspected violations of this sub13 section. 

14 ‘‘(B) RETALIATORY REPORTING.—A pro15 vider of services may not file a complaint or a 

16 report against a nurse with the appropriate 

17 State professional disciplinary agency because 

18 the nurse refused to comply with a request to 

19 work mandatory overtime. 

20 ‘‘(C) GOOD FAITH.—For purposes of this 

21 paragraph, a nurse is deemed to be acting in 

22 good faith if the nurse reasonably believes— 

23 ‘‘(i) that the information reported or 

24 disclosed is true; and 


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1 ‘‘(ii) that a violation has occurred or 

2 may occur. 

3 ‘‘(5) NOTICE.— 

4 ‘‘(A) REQUIREMENT TO POST NOTICE.— 

5 Each provider of services shall post conspicu6 ously in an appropriate location a sign (in a 

7 form specified by the Secretary) specifying 

8 rights of nurses under this subsection. 

9 ‘‘(B) RIGHT TO FILE COMPLAINT.—Such 

10 sign shall include a statement that a nurse may 

11 file a complaint with the Secretary against a 

12 provider of services who violates the provisions 

13 of this subsection and information with respect 

14 to the manner of filing such a complaint. 

15 ‘‘(6) POSTING OF NURSE SCHEDULES.—A pro16 vider of services shall regularly post in a conspicuous 

17 manner the nurse schedules (for such periods of 

18 time that the Secretary determines appropriate by 

19 type or class of provider of services) for the depart20 ment or unit involved, and shall make available upon 

21 request to nurses assigned to the department or unit 

22 the daily nurse schedule for such department or 

23 unit. 

24 ‘‘(7) CIVIL MONEY PENALTY.— 


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

2 impose a civil money penalty of not more than 

3 $10,000 for each knowing violation of the provi4 sions of this subsection committed by a provider 

5 of services. 

6 ‘‘(B) PATTERNS OF VIOLATIONS.—Not7 withstanding subparagraph (A), the Secretary 

8 shall provide for the imposition of more severe 

9 civil money penalties under this paragraph for 

10 providers of services that establish patterns of 

11 repeated violations of such provisions. 

12 ‘‘(C) ADMINISTRATION OF PENALTIES.— 

13 The provisions of section 1128A (other than 

14 subsections (a) and (b)) shall apply to a civil 

15 money penalty under this paragraph in the 

16 same manner as such provisions apply to a pen17 alty or proceeding under section 1128A(a). 

18 The Secretary shall publish on the Internet site of 

19 the Department of Health and Human Services the 

20 names of providers of services against which civil 

21 money penalties have been imposed under this para22 graph, the violation for which the penalty was im23 posed, and such additional information as the Sec24 retary determines appropriate. With respect to a 

25 provider of services that has had a change in ownerVerDate Aug 31 2005 03:30 Jul 21, 2007 Jkt 059200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S1842.IS S1842

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1 ship, as determined by the Secretary, penalties im2 posed on the provider of services while under pre3 vious ownership shall no longer be published by the 

4 Secretary on such Internet site after the 1-year pe5 riod beginning on the date of change in ownership. 

6 ‘‘(8) RULE OF CONSTRUCTION.—Nothing in 

7 this subsection shall be construed as precluding a 

8 nurse from voluntarily working more than any of the 

9 periods of time described in paragraph (1), so long 

10 as such work is done consistent with professional 

11 standards of safe patient care. 

12 ‘‘(9) DEFINITIONS.—In this subsection: 

13 ‘‘(A) MANDATORY OVERTIME.—The term 

14 ‘mandatory overtime’ means hours worked in 

15 excess of the periods of time described in para16 graph (1), except as provided in paragraph (2), 

17 pursuant to any request made by a provider of 

18 services to a nurse which, if refused or declined 

19 by the nurse involved, may result in an adverse 

20 employment consequence to the nurse, including 

21 discharge, discipline, loss of promotion, or retal22 iatory reporting of the nurse to the State pro23 fessional disciplinary agency involved. 


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1 ‘‘(B) OVERTIME.—The term ‘overtime’ 

2 means time worked in excess of the periods of 

3 time described in paragraph (1). 

4 ‘‘(C) NURSE.—The term ‘nurse’ means a 

5 registered nurse or a licensed practical nurse. 

6 ‘‘(D) PROVIDER OF SERVICES.—The term 

7 ‘provider of services’ means— 

8 ‘‘(i) a hospital (as defined in section 

9 1861(e)); 

10 ‘‘(ii) a psychiatric hospital (as defined 

11 in section 1861(f)); 

12 ‘‘(iii) a hospital outpatient depart13 ment; 

14 ‘‘(iv) a critical access hospital (as de15 fined in section 1861(mm)(1)); 

16 ‘‘(v) an ambulatory surgical center; 

17 ‘‘(vi) a home health agency (as de18 fined in section 1861(o)); 

19 ‘‘(vii) a rehabilitation agency; 

20 ‘‘(viii) a clinic, including a rural 

21 health clinic (as defined in section 

22 1861(aa)(2)); or 

23 ‘‘(ix) a Federally qualified health cen24 ter (as defined in section 1861(aa)(4)). 


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1 ‘‘(E) DECLARED STATE OF EMERGENCY.— 

2 The term ‘declared state of emergency’ means 

3 an officially designated state of emergency that 

4 has been declared by the Federal Government 

5 or the head of the appropriate State or local 

6 governmental agency having authority to de7 clare that the State, county, municipality, or lo8 cality is in a state of emergency, but does not 

9 include a state of emergency that results from 

10 a labor dispute in the health care industry or 

11 consistent understaffing. 

12 ‘‘(F) STANDARDS OF SAFE PATIENT

13 CARE.—The term ‘standards of safe patient 

14 care’ means the recognized professional stand15 ards governing the profession of the nurse in16 volved.’’. 

17 (b) EFFECTIVE DATE.—The amendments made by 

18 this section shall take effect 1 year after the date of enact19 ment of this Act. 

20 SEC. 4. REPORTS. 

21 (a) STANDARDS ON SAFE WORKING HOURS FOR

22 NURSES.— 

23 (1) STUDY.—The Secretary of Health and 

24 Human Services, acting through the Director of the 

25 Agency for Healthcare Research and Quality, shall 


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1 conduct a study to establish appropriate standards 

2 for the maximum number of hours that a nurse who 

3 furnishes health care to patients may work without 

4 compromising the safety of such patients. Such 

5 standards may vary by provider of service and by de6 partment within a provider of services, by duties or 

7 functions carried out by nurses, by shift, and by 

8 other factors that the Director determines appro9 priate. The Director may contract with an eligible 

10 entity or organization to carry out the study under 

11 this paragraph. 

12 (2) REPORT.—Not later than 2 years after the 

13 date of the enactment of this Act, the Secretary 

14 shall submit to Congress a report on the study con15 ducted under paragraph (1) and shall include rec16 ommendations for such appropriate standards of 

17 maximum work hours. 

18 (b) REPORT ON MANDATORY OVERTIME IN FEDER19 ALLY OPERATED MEDICAL FACILITIES.— 

20 (1) STUDY.— 

21 (A) IN GENERAL.—The Director of the Of22 fice of Management and Budget shall conduct 

23 a study to determine the extent to which feder24 ally operated medical facilities have in effect 

25 practices and policies with respect to overtime 


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1 requirements for nurses that are inconsistent 

2 with the provisions of section 1866(k) of the 

3 Social Security Act, as added by section 3. 

4 (B) FEDERALLY OPERATED MEDICAL FA5 CILITIES DEFINED.—In this subsection, the 

6 term ‘‘federally operated medical facilities’’ 

7 means acute care hospitals, freestanding clinics, 

8 and home health care clinics that are operated 

9 by the Department of Veterans Affairs, the De10 partment of Defense, or any other department 

11 or agency of the United States. 

12 (2) REPORT.—Not later than 6 months after 

13 the date of the enactment of this Act, the Director 

14 of the Office of Management and Budget shall sub15 mit to Congress a report on the study conducted 

16 under paragraph (1) and shall include recommenda17 tions for the implementation of policies within feder18 ally operated medical facilities with respect to over19 time requirements for nurses that are consistent 

20 with such section 1866(k), as so added. 

Æ 


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