I 

108TH CONGRESS 

2D SESSION H. R. 4374

To require Medicare providers to disclose publicly staffing and performance 

in order to promote improved consumer information and choice. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 17, 2004

Mr. HINCHEY introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy 

and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL

To require Medicare providers to disclose publicly staffing 

and performance in order to promote improved consumer 

information and choice.

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 ‘‘Patient Safety Act of 

5 2004’’. 

6 SEC. 2. FINDINGS. 

7 The Congress finds as follows: 
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1 (1) The past decade has been a turbulent time 

2 for health care facilities and nurses. 

3 (2) Recent research published in the Journal of 

4 the American Medical Association has shown that 

5 registered nurse staffing levels have a significant im6 pact on preventable deaths in hospitals, and that the 

7 odds of patient mortality increase 7 percent for 

8 every additional patient added to the average reg9 istered nurse’s workload. 

10 (3) Recent research supported by the Agency 

11 for Health Care Research and Quality, the Centers 

12 for Medicare & Medicaid Services, and the National 

13 Institute for Nursing Research shows that inad14 equate registered nurse staffing is directly related to 

15 serious complications such as pneumonia, upper gas16 trointestinal bleeding, and urinary tract infections, 

17 as well as failure to stop deaths caused by shock, 

18 cardiac arrest, sepsis, and deep vein thrombosis in 

19 hospitalized patients. 

20 (4) The Joint Commission on the Accreditation 

21 of Healthcare Organizations recently reported that 

22 inadequate nurse staffing contributes to nearly a 

23 quarter of all unexpected incidents that kill or injure 

24 hospitalized patients. 
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1 (5) The Institute of Medicine has reported that 

2 both nursing-to-resident staffing levels and the ratio 

3 of professional nurses to other nursing personnel are 

4 important indicators of high quality of care, and 

5 that the participation of registered nurses in direct 

6 care giving and in the provision of hands-on guid7 ance to nurse assistants is positively associated with 

8 quality of care in nursing facilities. 

9 (6) Recent research conducted by the Centers 

10 for Medicare & Medicaid Services found strong, ob11 jective proof that nurse staffing in nursing homes is 

12 directly related to quality measures such as sepsis, 

13 urinary tract infections, incidence of pressure sores, 

14 resisting care improvement, and weight loss. 

15 (7) As a payer for inpatient and outpatient hos16 pital services for individuals entitled to benefits 

17 under the medicare and medicaid programs estab18 lished under titles XVIII and XIX of the Social Se19 curity Act, the Federal Government has a compelling 

20 interest in promoting the safety of such individuals 

21 by requiring providers participating in such pro22 grams to provide these individuals with information 

23 regarding nurse staffing levels. 
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1 SEC. 3. PUBLIC DISCLOSURE OF STAFFING AND OUTCOMES 

2 DATA. 

3 (a) DISCLOSURE OF STAFFING AND OUTCOMES.—

4 Any provider under the medicare program shall, as a con5 dition of continued participation in such program, make 

6 publicly available information regarding nurse staffing 

7 and patient outcomes as specified by the Secretary. Such 

8 information shall include at least the following: 

9 (1) The number of registered nurses providing 

10 direct patient care. This information shall be ex11 pressed both in raw numbers, in terms of total hours 

12 of nursing care per patient (including adjustment for 

13 case mix and acuity), and as a percentage of nursing 

14 staff, and shall be broken down in terms of the total 

15 nursing staff, each unit, and each shift. 

16 (2) The number of licensed practical nurses or 

17 licensed vocational nurses providing direct care. This 

18 information shall be expressed both in raw numbers, 

19 in terms of total hours of nursing care per patient 

20 (including adjustment for case mix and acuity), and 

21 as a percentage of nursing staff, and shall be broken 

22 down in terms of the total nursing staff, each unit, 

23 and each shift. 

24 (3) Numbers of unlicensed personnel utilized to 

25 provide direct patient care. This information shall be 

26 expressed both in raw numbers and as a percentage 
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1 of nursing staff and shall be broken down in terms 

2 of the total nursing staff, each unit, and each shift. 

3 (4) The average number of patients per reg4 istered nurse, licensed practical nurse, or unlicensed 

5 personnel providing direct patient care. This infor6 mation shall be broken down in terms of the total 

7 nursing staff, each unit, and each shift. 

8 (5) Risk-adjusted patient mortality rate (in raw 

9 numbers and by diagnosis or diagnostic-related 

10 group). 

11 (6) Incidence of adverse patient care incidents, 

12 including as such incidents at least medication er13 rors, patient injury, pressure ulcers, nosocomial in14 fections, and nosocomial urinary tract infections. 

15 (7) Methods used for determining and adjusting 

16 staffing levels and patient care needs and the pro17 vider’s compliance with these methods. 

18 (b) DISCLOSURE OF COMPLAINTS.—Data regarding 

19 complaints filed with the State agency, the Centers for 

20 Medicare & Medicaid Services, or an accrediting agency, 

21 compliance with the standards of which have been deemed 

22 to demonstrate compliance with conditions of participation 

23 under the medicare program, and data regarding inves24 tigations and findings as a result of those complaints and 
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1 the findings of scheduled inspection visits, shall be made 

2 publicly available. 

3 (c) INFORMATION ON DATA.—All data made publicly 

4 available under this section shall indicate the source and 

5 currency of the data provided. 

6 (d) WAIVER FOR SMALL PROVIDERS.—The Secretary 

7 may reduce reporting requirements under this section in 

8 the case of a small provider (as defined by the Secretary) 

9 for whom the imposition of the requirements would be un10 duly burdensome. 

11 (e) REPORTING TO SECRETARY.—Providers shall 

12 submit to the Secretary in a uniform manner (as pre13 scribed by the Secretary) the nursing staff information de14 scribed in subsection (a) through electronic means not less 

15 frequently than quarterly. 

16 (f) SECRETARIAL RESPONSIBILITIES.—The Sec17 retary shall—

18 (1) make the information submitted pursuant 

19 to subsection (a) publicly available, including by 

20 publication of such information on the Internet site 

21 of the Department of Health and Human Services; 

22 and 

23 (2) provide for the auditing of such information 

24 for accuracy as a part of the process of determining 
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1 whether a provider is eligible for continued partici2 pation in the medicare program. 

3 (g) DEFINITIONS.—For purposes of this section: 

4 (1) LICENSED PRACTICAL NURSE OR LICENSED

5 VOCATIONAL NURSE.—The term ‘‘licensed practical 

6 nurse or licensed vocational nurse’’ means an indi7 vidual who is entitled under State law or regulation 

8 to practice as a licensed practical nurse or a licensed 

9 vocational nurse. 

10 (2) PUBLICLY AVAILABLE.—The term ‘‘publicly 

11 available’’ means, with respect to information of a 

12 provider, information that is—

13 (A) provided to the Secretary and to any 

14 State agency responsible for licensing or accred15 iting the provider; 

16 (B) provided to any State agency which 

17 approves or oversees health care services deliv18 ered by the provider directly or through an in19 suring entity or corporation; and 

20 (C) provided to any member of the public 

21 which requests such information directly from 

22 the provider. 

23 (3) MEDICARE PROGRAM.—The term ‘‘medicare 

24 program’’ means the programs under title XVIII of 

25 the Social Security Act. 
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1 (4) PROVIDER.—The term ‘‘provider’’ means an 

2 entity that is—

3 (A) a psychiatric hospital described in sec4 tion 1861(f) of the Social Security Act (42 

5 U.S.C. 1395x(f)); 

6 (B) a provider of services described in sec7 tion 1861(u) of such Act (42 U.S.C. 1395x(u)), 

8 other than a skilled nursing facility, as defined 

9 in section 1819(a) of such Act (42 U.S.C. 

10 1395i–3(a)); 

11 (C) a rural health clinic described in sec12 tion 1861(aa)(2) of such Act (42 U.S.C. 

13 1395x(aa)(2)); 

14 (D) an ambulatory surgical center de15 scribed in section 1832(a)(2)(F)(i) of such Act 

16 (42 U.S.C. 1395k(a)(2)(F)(i)); or 

17 (E) a renal dialysis facility described in 

18 section 1881(b)(1)(A) of such Act (42 U.S.C. 

19 1395rr(b)(1)(A)). 

20 (5) REGISTERED NURSE.—The term ‘‘reg21 istered nurse’’ means an individual who is entitled 

22 under State law or regulation to practice as a reg23 istered nurse. 

24 (6) SECRETARY.—The term ‘‘Secretary’’ means 

25 the Secretary of Health and Human Services. 
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1 SEC. 4. PUBLIC DISCLOSURE OF ACCURATE DATA ON 

2 NURSING FACILITY STAFFING. 

3 (a) MEDICARE.—Section 1819(b)(8) of the Social Se4 curity Act (42 U.S.C. 1395i–3(b)) is amended—

5 (1) in subparagraph (A), by adding at the end 

6 the following new sentence: ‘‘The information posted 

7 under this subparagraph shall include information 

8 regarding nurse staffing with respect to beds made 

9 available by reason of an agreement under section 

10 1883.’’; and 

11 (2) by adding at the end the following new sub12 paragraphs: 

13 ‘‘(C) SUBMISSION AND POSTING OF

14 DATA.—

15 ‘‘(i) IN GENERAL.—Beginning on Jan16 uary 1, 2005, a skilled nursing facility 

17 shall submit to the Secretary in a uniform 

18 manner (as prescribed by the Secretary) 

19 the nursing staff data described in section 

20 3(a) of the Patient Safety Act of 2004 

21 through electronic means not less fre22 quently than quarterly and the Secretary 

23 shall make such data publicly available (as 

24 defined in section 3(g)(2) of such Act), in25 cluding by posting such data on an Inter26 net website. 
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1 ‘‘(ii) INFORMATION ON NURSE

2 AIDES.—In addition to the nursing staff 

3 data described in clause (i), a skilled nurs4 ing facility shall submit to the Secretary 

5 the numbers of nurse aides (as defined in 

6 paragraph (5))(F)) utilized to provide di7 rect patient care. This information shall be 

8 expressed both in raw numbers and as a 

9 percentage of nursing staff and shall be 

10 broken down in terms of the total nursing 

11 staff, each unit, and each shift. 

12 ‘‘(D) AUDIT OF DATA.—As part of each 

13 standard survey conducted under subsection 

14 (g)(2)(A), there shall be an audit of the nursing 

15 staff data reported under subparagraph (C) to 

16 ensure that such data are accurate.’’. 

17 (b) MEDICAID.—Section 1919(b)(8) of the Social Se18 curity Act (42 U.S.C. 1395r(b)(8)) is amended—

19 (1) in subparagraph (A), by adding at the end 

20 the following new sentence: ‘‘The information posted 

21 under this subparagraph shall include information 

22 regarding nurse staffing with respect to beds made 

23 available by reason of an agreement under section 

24 1883.’’; and 
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1 (2) by adding at the end the following new sub2 paragraphs: 

3 ‘‘(C) SUBMISSION AND POSTING OF

4 DATA.—

5 ‘‘(i) IN GENERAL.—Beginning on Jan6 uary 1, 2005, a nursing facility shall sub7 mit to the Secretary in a uniform manner 

8 (as prescribed by the Secretary) the nurs9 ing staff data described in section 3(a) of 

10 the Patient Safety Act of 2004 through 

11 electronic means not less frequently than 

12 quarterly and the Secretary shall make 

13 such data publicly available (as defined in 

14 section 3(g)(2) of such Act), including by 

15 posting such data on an Internet website. 

16 ‘‘(ii) INFORMATION ON NURSE

17 AIDES.—In addition to the nursing staff 

18 data described in clause (i), a skilled nurs19 ing facility shall submit to the Secretary 

20 the numbers of nurse aides (as defined in 

21 paragraph (5))(F)) utilized to provide di22 rect patient care. This information shall be 

23 expressed both in raw numbers and as a 

24 percentage of nursing staff and shall be 
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1 broken down in terms of the total nursing 

2 staff, each unit, and each shift. 

3 ‘‘(D) AUDIT OF DATA.—As part of each 

4 standard survey conducted under subsection 

5 (g)(2)(A), there shall be an audit of the nursing 

6 staff data reported under subparagraph (C) to 

7 ensure that such data are accurate.’’. 

8 SEC. 5. CREATING A STAFFING QUALITY MEASURE FOR 

9 CONSUMERS TO COMPARE NURSING FACILI10 TIES. 

11 (a) IN GENERAL.—Beginning no later than 90 days 

12 after the date of the enactment of this Act, and for as 

13 long as the Secretary of Health and Human Services pub14 lishes quality measures to help the public compare the 

15 quality of care that nursing facilities provide, these quality 

16 measures shall include a quality measure for nursing staff 

17 that—

18 (1) reflects the average daily total nursing 

19 hours worked for the quarterly reporting period for 

20 which data are submitted under sections 

21 1819(b)(8)(C) and 1919(b)(8)(C) of the Social Secu22 rity Act (as added by subsections (a)(2) and (b)(2), 

23 respectively, of section 4), as well as, in the case of 

24 a skilled nursing facility, other information required 

25 to be reported under section 3(a); 
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1 (2) is sensitive to case mix and quality out2 comes; 

3 (3) indicates the percentile in which each nurs4 ing facility falls compared with other nursing facili5 ties in the State; 

6 (4) indicates the rate of retention of registered 

7 nurses, licensed practical nurses, and certified nurse 

8 assistants; and 

9 (5) includes such other measures as the Sec10 retary determines to be appropriate. 

11 The Secretary shall not be required to comply with the 

12 requirements of paragraph (2) to the extent that the devel13 opment of a methodology to comply with such requirement 

14 would delay the implementation of this section. 

15 (b) FORM AND MANNER.—The nursing facility com16 parative staffing measure described in subsection (a) shall 

17 be displayed in the same form and manner as information 

18 that the Secretary displays to help the public compare the 

19 quality of care that nursing facilities provide. 

20 SEC. 6. PROTECTION OF CERTAIN ACTIVITIES BY EMPLOY21 EES OF MEDICARE PROVIDERS. 

22 (a) IN GENERAL.—Subject to subsection (c), no pro23 vider under the medicare program shall terminate or take 

24 other adverse employment action (including the failure to 

25 promote an individual or provide any employment-related 
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1 benefit, an adverse evaluation or decision made in relation 

2 to accreditation, certification, credentialing or licensing of 

3 an individual, or other adverse personnel action) against 

4 any employee or group of employees for actions taken for 

5 the purpose of—

6 (1) notifying the provider of conditions which 

7 the employee or group of employees identifies, in 

8 communications with the provider, as dangerous or 

9 potentially dangerous or injurious to—

10 (A) patients who currently receive services 

11 from the provider; 

12 (B) individuals who are likely to receive 

13 services from the provider; or 

14 (C) employees of the provider; 

15 (2) notifying a Federal or State agency or an 

16 accreditation agency, compliance with the standards 

17 of which have been deemed to demonstrate compli18 ance with conditions of participation under the medi19 care program, of such conditions as are identified in 

20 paragraph (1); 

21 (3) notifying other individuals of conditions 

22 which the employee or group of employees reason23 ably believe to be such as are described in paragraph 

24 (1); 
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1 (4) discussing such conditions as are identified 

2 in paragraph (1) with other employees for the pur3 poses of initiating action described in paragraph (1), 

4 (2), or (3); or 

5 (5) other related activities as specified in regu6 lations promulgated by the Secretary of Health and 

7 Human Services. 

8 (b) SANCTION.—A provider that takes an action in 

9 violation of subsection (a) is subject to a civil money pen10 alty of not more than $20,000 for each such action. The 

11 provisions of section 1128A of the Social Security Act 

12 (other than subsections (a) and (b)) shall apply to civil 

13 money penalties under this subsection in the same manner 

14 as they apply to a penalty or proceeding under section 

15 1128A(a) of such Act. 

16 (c) EXCEPTION.—The provisions of subsection (a) 

17 shall not apply to the knowing or reckless provision of sub18 stantially false information by an employee or group of 

19 employees. 

20 SEC. 7. REPORT. 

21 Not later than 90 days after the date of the enact22 ment of this Act, the Secretary of Health and Human 

23 Services shall submit to Congress a report on—

24 (1) the manner in which the Secretary intends 

25 to implement reporting of additional nurse staffing 
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1 variables such as unit worked, day of week (weekday 

2 and weekend), and type of care (direct or adminis3 trative) provided; and 

4 (2) the most effective mechanisms for auditing 

5 nurse staffing data under sections 1819(b)(8)(D) 

6 and 1919(b)(8)(D) of the Social Security Act (as 

7 added by subsections (a)(2) and (b)(2), respectively, 

8 of section 4) and for auditing nurse staffing date 

9 under section 3(f)(2).

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