I 

108TH CONGRESS 

2D SESSION H. R. 4316

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 HOUSE OF REPRESENTATIVES 

MAY 6, 2004

Ms. SCHAKOWSKY (for herself, Mr. ANDREWS, Mr. CONYERS, Ms. DELAURO, 

Mr. DEUTSCH, Mr. FILNER, Mr. FROST, Mr. HOEFFEL, Mr. HOLDEN, 

Ms. EDDIE BERNICE JOHNSON of Texas, Mrs. MCCARTHY of New York, 

Mr. MEEK of Florida, Mr. NADLER, Ms. NORTON, Ms. ROYBAL-ALLARD, 

Ms. LINDA T. SA ́NCHEZ of California, and Mr. VISCLOSKY) introduced 

the following bill; which was referred to the Committee on Energy and 

Commerce, and in addition to the Committee on Ways and Means, for 

a period to be subsequently determined by the Speaker, in each case for 

consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL

To amend 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,
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1 SECTION 1. SHORT TITLE; FINDINGS. 

2 (a) SHORT TITLE.—This Act may be cited as the 

3 ‘‘Nurse Staffing Standards for Patient Safety and Quality 

4 Care Act of 2004’’. 

5 (b) FINDINGS.—Congress finds the following: 

6 (1) The Federal Government has a substantial 

7 interest in promoting quality care and improving the 

8 delivery of health care services to patients in health 

9 care facilities in the United States. 

10 (2) Recent changes in health care delivery sys11 tems that have resulted in higher acuity levels 

12 among patients in health care facilities increase the 

13 need for improved quality measures in order to pro14 tect patient care and reduce the incidence of medical 

15 errors. 

16 (3) Inadequate and poorly monitored registered 

17 nurse staffing practices that result in too few reg18 istered nurses providing direct care jeopardize the 

19 delivery of quality health care services. 

20 (4) Numerous studies have shown that patient 

21 outcomes are directly correlated to direct care reg22 istered nurse staffing levels, including a 2002 Joint 

23 Commission on Accreditation of Healthcare Organi24 zations report that concluded that the lack of direct 

25 care registered nurses contributed to nearly a quar-
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1 ter of the unanticipated problems that result in in2 jury or death to hospital patients. 

3 (5) Requirements for direct care registered 

4 nurse staffing ratios will help address the registered 

5 nurse shortage in the United States by aiding in re6 cruitment of new registered nurses and improving 

7 retention of registered nurses who are considering 

8 leaving direct patient care because of demands cre9 ated by inadequate staffing. 

10 (6) Establishing adequate minimum direct care 

11 registered nurse-to-patient ratios that take into ac12 count patient acuity measures will improve the deliv13 ery of quality health care services and guarantee pa14 tient safety. 

15 (7) Establishing safe staffing standards for di16 rect care registered nurses is a critical component of 

17 assuring that there is adequate hospital staffing at 

18 all levels to improve the delivery of quality care and 

19 protect patient safety. 

20 SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE 

21 STAFFING REQUIREMENT. 

22 (a) MINIMUM DIRECT CARE REGISTERED NURSE

23 STAFFING REQUIREMENT.—The Public Health Service 

24 Act (42 U.S.C. 201 et seq.) is amended by adding at the 

25 end the following new title: 
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1 ‘‘TITLE XXIX—MINIMUM DIRECT 

2 CARE REGISTERED NURSE 

3 STAFFING REQUIREMENT 

4 ‘‘SEC. 2901. MINIMUM NURSE STAFFING REQUIREMENT. 

5 ‘‘(a) STAFFING PLAN.—

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

7 a staffing plan that—

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

9 quality delivery of health care services and pro10 tects patient safety; and 

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

12 this title. 

13 ‘‘(2) EFFECTIVE DATES.—

14 ‘‘(A) IMPLEMENTATION OF STAFFING

15 PLAN.—Subject to subparagraph (B), the re16 quirements under paragraph (1) shall take ef17 fect not later than 1 year after the date of the 

18 enactment of this title. 

19 ‘‘(B) APPLICATION OF MINIMUM DIRECT

20 CARE REGISTERED NURSE-TO-PATIENT RA21 TIOS.—The requirements under subsection (b) 

22 shall take effect as soon as practicable, as de23 termined by the Secretary, but not later than 2 

24 years after the date of the enactment of this 

25 title, or in the case of a hospital in a rural area 
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1 (as defined in section 1886(d)(2)(B) of the So2 cial Security Act (42 U.S.C. 1395ww(d)(2)(B)), 

3 not later than 4 years after the date of the en4 actment of this title. 

5 ‘‘(b) MINIMUM DIRECT CARE REGISTERED NURSE6 TO-PATIENT RATIOS.—

7 ‘‘(1) IN GENERAL.—A hospital’s staffing plan 

8 shall provide that, during each shift within a unit of 

9 the hospital, a direct care registered nurse may be 

10 assigned to not more than the following number of 

11 patients in that unit, subject to paragraph (3): 

12 ‘‘(A) 1 patient in operating room units and 

13 trauma emergency units. 

14 ‘‘(B) 2 patients in critical care units, in15 cluding emergency critical care and intensive 

16 care units, labor and delivery units, and 

17 postanesthesia units. 

18 ‘‘(C) 3 patients in antepartum units, emer19 gency room units, pediatrics units, stepdown 

20 units, and telemetry units. 

21 ‘‘(D) 4 patients in intermediate care nurs22 ery units, medical/surgical units, and acute care 

23 psychiatric units. 

24 ‘‘(E) 5 patients in rehabilitation units. 
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1 ‘‘(F) 6 patients in postpartum (3 couplets) 

2 units and well-baby nursery units. 

3 ‘‘(2) SIMILAR UNITS WITH DIFFERENT

4 NAMES.—The Secretary may apply minimum direct 

5 care registered nurse-to-patient ratios established in 

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

7 to in such paragraph if such other unit performs a 

8 function similar to the function performed by the 

9 unit referred to in such paragraph. 

10 ‘‘(3) ADJUSTMENT OF RATIOS.—

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

12 patient safety, the Secretary may prescribe reg13 ulations that—

14 ‘‘(i) increase minimum direct care reg15 istered nurse-to-patient ratios under this 

16 subsection to further limit the number of 

17 patients that may be assigned to each di18 rect care nurse; or 

19 ‘‘(ii) add minimum direct care reg20 istered nurse-to-patient ratios for units not 

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

22 ‘‘(B) CONSULTATION.—Such regulations 

23 shall be prescribed after consultation with af24 fected hospitals and registered nurses. 
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1 ‘‘(4) RELATIONSHIP TO STATE-IMPOSED RA2 TIOS.—

3 ‘‘(A) NO PREEMPTION OF CERTAIN STATE4 IMPOSED RATIOS.—Nothing in this title shall 

5 preempt State standards that the Secretary de6 termines to be at least equivalent to Federal re7 quirements for a staffing plan established under 

8 this title. Minimum direct care registered nurse9 to-patient ratios established under this sub10 section shall not preempt State requirements 

11 that the Secretary determines are at least 

12 equivalent to Federal requirements for a staff13 ing plan established under this title. 

14 ‘‘(B) SATISFACTION OF CERTAIN FEDERAL

15 REQUIREMENTS WITH CERTAIN STATE-IMPOSED

16 NURSE-TO-PATIENT RATIOS.—States that, at 

17 least 2 years prior to the date of the enactment 

18 of this title, have enacted minimum direct care 

19 nurse-to-patient ratios that allow the use of li20 censed practical nurses to meet State-imposed 

21 minimum direct care nurse-to-patient ratios 

22 may continue to make such allowance, and such 

23 allowance shall be considered to satisfy require24 ments imposed under this subsection, so long as 
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1 the particular licensed practical nurse is em2 ployed in the same or a comparable position. 

3 ‘‘(5) EXEMPTION IN EMERGENCIES.—

4 ‘‘(A) IN GENERAL.—The requirements es5 tablished under this subsection shall not apply 

6 during a declared state of emergency if a hos7 pital is requested or expected to provide an ex8 ceptional level of emergency or other medical 

9 services. 

10 ‘‘(B) EMERGENCY DEFINED.—For pur11 poses of subparagraph (A), the term ‘declared 

12 state of emergency’ means a state of emergency 

13 that has been declared by the Federal Govern14 ment or the head of the appropriate State or 

15 local governmental agency having authority to 

16 declare that the State, county, municipality, or 

17 locality is in a state of emergency, but such 

18 term does not include a state of emergency that 

19 results from a labor dispute in the health care 

20 industry or consistent understaffing. 

21 ‘‘(c) DEVELOPMENT AND REEVALUATION OF STAFF22 ING PLAN.—

23 ‘‘(1) CONSIDERATIONS IN DEVELOPMENT OF

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

25 shall provide for direct care registered nurse-to-pa-
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1 tient ratios above the minimum direct care reg2 istered nurse-to-patient ratios required under sub3 section (b) if appropriate based upon consideration 

4 of the following factors: 

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

6 level of patients as determined by the applica7 tion of an acuity system (as defined in section 

8 2906(1)), on a shift-by-shift basis. 

9 ‘‘(B) The anticipated admissions, dis10 charges, and transfers of patients during each 

11 shift that impacts direct patient care. 

12 ‘‘(C) Specialized experience required of di13 rect care registered nurses on a particular unit. 

14 ‘‘(D) Staffing levels and services provided 

15 by other health care personnel in meeting direct 

16 patient care needs not required by a direct care 

17 registered nurse. 

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

19 affects the delivery of direct patient care. 

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

21 practices, policies, and procedures by temporary 

22 agency direct care registered nurses used dur23 ing a shift. 

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

25 of patient care presented by physical layout. 
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1 ‘‘(2) DOCUMENTATION OF STAFFING.—A hos2 pital shall specify the system used to document ac3 tual staffing in each unit for each shift. 

4 ‘‘(3) ANNUAL REEVALUATION OF PLAN AND

5 ACUITY SYSTEM.—

6 ‘‘(A) IN GENERAL.—A hospital shall annu7 ally evaluate—

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

9 relation to actual patient care require10 ments; and 

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

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

13 staffing plan and acuity system to the extent 

14 appropriate based on such evaluation. 

15 ‘‘(4) REGISTERED NURSE PARTICIPATION.—A 

16 staffing plan of a hospital shall be developed and 

17 subsequent reevaluations shall be conducted under 

18 this subsection on the basis of input from direct care 

19 registered nurses at the hospital or, where such 

20 nurses are represented through collective bargaining, 

21 from the applicable recognized or certified collective 

22 bargaining representative of such nurses. Nothing in 

23 this title shall be construed to permit conduct pro24 hibited under the National Labor Relations Act or 

25 under the Federal Labor Relations Act. 
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1 ‘‘(d) SUBMISSION OF PLAN TO SECRETARY.—A hos2 pital shall submit to the Secretary its staffing plan and 

3 any annual updates under subsection (c)(3)(B). A feder4 ally operated hospital may submit its staffing plan 

5 through the department or agency operating the hospital. 

6 ‘‘SEC. 2902. POSTING, RECORDS, AND AUDITS. 

7 ‘‘(a) POSTING REQUIREMENTS.—In each unit, a hos8 pital shall post a uniform notice in a form specified by 

9 the Secretary in regulation that—

10 ‘‘(1) explains requirements imposed under sec11 tion 2901; 

12 ‘‘(2) includes actual direct care registered 

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

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

15 staff, patients, and the public. 

16 ‘‘(b) RECORDS.—

17 ‘‘(1) MAINTENANCE OF RECORDS.—Each hos18 pital shall maintain accurate records of actual direct 

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

20 for each shift for no less than 3 years. Such records 

21 shall include—

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

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

24 direct care registered nurse assigned to each 

25 patient in each unit in each shift; and 
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1 ‘‘(C) a copy of each notice posted under 

2 subsection (a). 

3 ‘‘(2) AVAILABILITY OF RECORDS.—Each hos4 pital shall make its records maintained under para5 graph (1) available to—

6 ‘‘(A) the Secretary; 

7 ‘‘(B) registered nurses and their collective 

8 bargaining representatives (if any); and 

9 ‘‘(C) the public under regulations estab10 lished by the Secretary, or in the case of a fed11 erally operated hospital, under section 552 of 

12 title 5, United States Code (commonly known 

13 as the ‘Freedom of Information Act’). 

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

15 audits to ensure—

16 ‘‘(1) implementation of the staffing plan in ac17 cordance with this title; and 

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

19 section. 

20 ‘‘SEC. 2903. MINIMUM DIRECT CARE LICENSED PRACTICAL 

21 NURSE STAFFING REQUIREMENTS. 

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

23 shall comply with minimum direct care licensed practical 

24 nurse staffing requirements that the Secretary establishes 

25 for units in hospitals. Such staffing requirements shall be 
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1 established not later than 18 months after the date of the 

2 enactment of this title, and shall be based on the study 

3 conducted under subsection (b). 

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

5 of the enactment of this title, the Secretary, acting 

6 through the Director of the Agency for Healthcare Re7 search and Quality, shall complete a study of licensed 

8 practical nurse staffing and its effects on patient care in 

9 hospitals. The Director may contract with a qualified enti10 ty or organization to carry out such study under this para11 graph. The Director shall consult with licensed practical 

12 nurses and organizations representing licensed practical 

13 nurses regarding the design and conduct of the study. 

14 ‘‘(c) APPLICATION OF REGISTERED NURSE PROVI15 SIONS TO LICENSED PRACTICAL NURSE STAFFING RE16 QUIREMENTS.—Paragraphs (2), (3), (4)(A), and (5) of 

17 section 2901(b), section 2901(c), and section 2902 shall 

18 apply to the establishment and application of direct care 

19 licensed practical nurse staffing requirements under this 

20 section in the same manner that they apply to the estab21 lishment and application of direct care registered nurse22 to-patient ratios under section 2901. 

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

24 section shall take effect as soon as practicable, as deter25 mined by the Secretary, but not later than 2 years after 
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1 the date of the enactment of this title, or in the case of 

2 a hospital in a rural area (as defined in section 

3 1886(d)(2)(B) of the Social Security Act (42 U.S.C. 

4 1395ww(d)(2)(B)), not later than 4 years after the date 

5 of the enactment of this title. 

6 ‘‘SEC. 2904. ADJUSTMENT IN REIMBURSEMENT. 

7 ‘‘(a) MEDICARE REIMBURSEMENT.—The Secretary 

8 shall adjust payments made to hospitals (other than feder9 ally operated hospitals) under title XVIII of the Social Se10 curity Act in an amount equal to the net amount of addi11 tional costs incurred in providing services to medicare 

12 beneficiaries that are attributable to compliance with re13 quirements imposed under sections 2901 through 2903. 

14 The amount of such payment adjustments shall take into 

15 account recommendations contained in the report sub16 mitted by the Medicare Payment Advisory Commission 

17 under subsection (c). 

18 ‘‘(b) AUTHORIZATION OF APPROPRIATION FOR FED19 ERALLY OPERATED HOSPITALS.—There are authorized to 

20 be appropriated such additional sums as are required for 

21 federally operated hospitals to comply with the additional 

22 requirements established under sections 2901 through 

23 2903. 

24 ‘‘(c) MEDPAC REPORT.—Not later than 2 years 

25 after the date of the enactment of this title, the Medicare 
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1 Payment Advisory Commission (established under section 

2 1805 of the Social Security Act (42 U.S.C. 1395b-6)) shall 

3 submit to Congress and the Secretary a report estimating 

4 total costs and savings attributable to compliance with re5 quirements imposed under sections 2901 through 2903. 

6 Such report shall include recommendations on the need, 

7 if any, to adjust reimbursement for Medicare payments 

8 under subsection (a). 

9 ‘‘SEC. 2905. PROTECTION OF NURSES AND OTHER INDIVID10 UALS. 

11 ‘‘(a) REFUSAL OF ASSIGNMENT.—A nurse may 

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

13 if—

14 ‘‘(1) the assignment would violate section 2901 

15 or 2903; or 

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

17 training, or experience to fulfill the assignment with18 out compromising the safety of any patient or jeop19 ardizing the license of the nurse. 

20 ‘‘(b) RETALIATION FOR REFUSAL OF ASSIGNMENT

21 BARRED.—

22 ‘‘(1) NO DISCHARGE, DISCRIMINATION, OR RE23 TALIATION.—No hospital shall discharge, discrimi24 nate, or retaliate in any manner with respect to any 

25 aspect of employment (as defined in section 
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1 2906(5)), including discharge, promotion, compensa2 tion, or terms, conditions, or privileges of employ3 ment against a nurse based on the nurse’s refusal of 

4 a work assignment under subsection (a). 

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

6 shall file a complaint or a report against a nurse 

7 with the appropriate State professional disciplinary 

8 agency because of the nurse’s refusal of a work as9 signment under subsection (a). 

10 ‘‘(c) CAUSE OF ACTION.—Any nurse who has been 

11 discharged, discriminated, or retaliated against in viola12 tion of subsection (b)(1) or against whom a complaint has 

13 been filed in violation of subsection (b)(2) may bring a 

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

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

16 one or more of the following: 

17 ‘‘(1) Reinstatement. 

18 ‘‘(2) Reimbursement of lost wages, compensa19 tion, and benefits. 

20 ‘‘(3) Attorneys’ fees. 

21 ‘‘(4) Court costs. 

22 ‘‘(5) Other damages. 

23 ‘‘(d) COMPLAINT TO SECRETARY.—A nurse or other 

24 individual may file a complaint with the Secretary against 
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1 a hospital that violates the provisions of this title. For any 

2 complaint filed, the Secretary shall—

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

4 ‘‘(2) determine whether a violation of this title 

5 as alleged in the complaint has occurred; and 

6 ‘‘(3) if such a violation has occurred, issue an 

7 order that the complaining nurse or individual shall 

8 not suffer any retaliation under subsection (b) or 

9 under subsection (e). 

10 ‘‘(e) PROTECTION FOR REPORTING.—

11 ‘‘(1) RETALIATION BARRED.—A hospital shall 

12 not discriminate or retaliate in any manner with re13 spect to any aspect of employment, including hiring, 

14 discharge, promotion, compensation, or terms, condi15 tions, or privileges of employment against any indi16 vidual who in good faith, individually or in conjunc17 tion with another person or persons—

18 ‘‘(A) reports a violation or a suspected vio19 lation of this title to the Secretary, a public reg20 ulatory agency, a private accreditation body, or 

21 the management personnel of the hospital; 

22 ‘‘(B) initiates, cooperates, or otherwise 

23 participates in an investigation or proceeding 

24 brought by the Secretary, a public regulatory 
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1 agency, or a private accreditation body con2 cerning matters covered by this title; or 

3 ‘‘(C) informs or discusses with other indi4 viduals or with representatives of hospital em5 ployees a violation or suspected violation of this 

6 title. 

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

8 this subsection, an individual shall be deemed to be 

9 acting in good faith if the individual reasonably be10 lieves—

11 ‘‘(A) the information reported or disclosed 

12 is true; and 

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

14 or may occur. 

15 ‘‘(f) NOTICE.—A hospital shall post in an appropriate 

16 location in each unit a conspicuous notice in a form speci17 fied by the Secretary that—

18 ‘‘(1) explains the rights of nurses and other in19 dividuals under this section; 

20 ‘‘(2) includes a statement that a nurse or other 

21 individual may file a complaint with the Secretary 

22 against a hospital that violates the provisions of this 

23 title; and 

24 ‘‘(3) provides instructions on how to file a com25 plaint under paragraph (2). 
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1 ‘‘(g) EFFECTIVE DATES.—

2 ‘‘(1) REFUSAL; RETALIATION; CAUSE OF AC3 TION.—

4 ‘‘(A) IN GENERAL.—Subsections (a) 

5 through (c) shall apply to refusals occurring on 

6 or after the effective date of the provision to 

7 which the refusal relates. 

8 ‘‘(B) EXCEPTION.—Subsection (a)(2) shall 

9 not apply to refusals in any hospital before the 

10 requirements of section 2901(a) apply to that 

11 hospital. 

12 ‘‘(2) PROTECTIONS FOR REPORTING.—Sub13 section (e) shall apply to actions described in sub14 paragraphs (A) and (C) of subsection (e)(1) occur15 ring on or after the effective date of the provision 

16 to which the violation relates. Subsection (e) shall 

17 apply to initiation, cooperation, or participation in 

18 an investigation or proceeding on or after the date 

19 of the enactment of this title. 

20 ‘‘(3) NOTICE.—Subsection (f) shall take effect 

21 18 months after the date of the enactment of this 

22 title. 

23 ‘‘SEC. 2906. DEFINITIONS. 

24 ‘‘For purposes of this title: 
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1 ‘‘(1) ACUITY SYSTEM.—The term ‘acuity sys2 tem’ means an established measurement tool that—

3 ‘‘(A) predicts nursing care requirements 

4 for individual patients based on severity of pa5 tient illness, need for specialized equipment and 

6 technology, intensity of nursing interventions 

7 required, and the complexity of clinical nursing 

8 judgment needed to design, implement, and 

9 evaluate the patient’s nursing care plan; 

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

11 needed, both in number of nurses and in skill 

12 mix of nursing personnel required, on a daily 

13 basis, for each patient in a nursing department 

14 or unit; 

15 ‘‘(C) takes into consideration the patient 

16 care services provided not only by registered 

17 nurses but also by direct care licensed practical 

18 nurses and other health care personnel; and 

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

20 used and understood by nurses. 

21 ‘‘(2) DIRECT CARE LICENSED PRACTICAL

22 NURSE.—The term ‘direct care licensed practical 

23 nurse’ means an individual who has been granted a 

24 license by at least 1 State to practice as a licensed 
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1 practical nurse or a licensed vocational nurse and 

2 who provides bedside care for 1 or more patients. 

3 ‘‘(3) NURSE.—The term ‘nurse’ means any di4 rect care registered nurse or direct care licensed 

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

6 whether or not the nurse is an employee. 

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

8 term ‘direct care registered nurse’ means an indi9 vidual who has been granted a license by at least 1 

10 State to practice as a registered nurse and who pro11 vides bedside care for 1 or more patients. 

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

13 includes the provision of services under a contract or 

14 other arrangement. 

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

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

17 Social Security Act (42 U.S.C. 1395x(e)), and in18 cludes a hospital that is operated by the Department 

19 of Veterans Affairs, the Department of Defense, the 

20 Indian Health Services Program, or any other de21 partment or agency of the United States. 

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

23 means a staffing plan required under section 2901.’’. 

24 (b) RECOMMENDATIONS TO CONGRESS.—No later 

25 than 1 year after the date of the enactment of this Act, 
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1 the Secretary of Health and Human Services shall submit 

2 to Congress a report containing recommendations for en3 suring that sufficient numbers of nurses are available to 

4 meet the requirements imposed by title XXIX of the Pub5 lic Health Service Act, as added by subsection (a). 

6 SEC. 3. ENFORCEMENT OF REQUIREMENTS THROUGH FED7 ERAL PROGRAMS. 

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

9 Social Security Act (42 U.S.C. 1395cc(a)(1)), as amended 

10 by the Medicare Prescription Drug, Improvement, and 

11 Modernization Act of 2003 (Public Law 108–173), is 

12 amended— 

13 (1) by striking ‘‘and’’ at the end of subpara14 graph (U); 

15 (2) by striking the period at the end of sub16 paragraph (V) and inserting ‘‘, and’’; and 

17 (3) by inserting after subparagraph (V) the fol18 lowing: 

19 ‘‘(W) in the case of a hospital, to comply 

20 with the provisions of title XXIX of the Public 

21 Health Service Act.’’. 

22 (b) MEDICAID PROGRAM.—The first sentence of sec23 tion 1902(a) of the Social Security Act (42 U.S.C. 

24 1396(a)) is amended—
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1 (1) by striking ‘‘and’’ at the end of paragraph 

2 (66); 

3 (2) by striking the period at the end of para4 graph (67) and inserting ‘‘; and’’; and 

5 (3) by inserting after paragraph (67) the fol6 lowing new paragraph: 

7 ‘‘(68) provide that any hospital receiving pay8 ments under such plan must comply with the provi9 sions of title XXIX of the Public Health Service 

10 Act.’’. 

11 (c) HEALTH BENEFITS PROGRAM OF THE DEPART12 MENT OF VETERANS AFFAIRS.—Section 8110(a) of title 

13 38, United States Code, is amended by adding at the end 

14 the following new paragraph: 

15 ‘‘(7) In the case of a Department medical facility that 

16 is a hospital, the hospital shall comply with the provisions 

17 of title XXIX of the Public Health Service Act.’’. 

18 (d) HEALTH BENEFITS PROGRAM OF THE DEPART19 MENT OF DEFENSE.—

20 (1) IN GENERAL.—Chapter 55 of title 10, 

21 United States Code, is amended by adding at the 

22 end the following new section: 
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1 ‘‘§ 1110a. Staffing requirements 

2 ‘‘In the case of a facility of the uniformed services 

3 that is a hospital, the hospital shall comply with the provi4 sions of title XXIX of the Public Health Service Act.’’. 

5 (2) CLERICAL AMENDMENT.—The table of sec6 tions at the beginning of such chapter is amended 

7 by inserting after the item relating to section 1110 

8 the following new item:

‘‘1110a. Staffing requirements.’’.

9 (e) INDIAN HEALTH SERVICES PROGRAM.—Title 

10 VIII of the Indian Health Care Improvement Act (25 

11 U.S.C. 1671 et seq.) is amended by adding at the end 

12 the following new section: 

13 ‘‘SEC. 826 STAFFING REQUIREMENTS. 

14 ‘‘A hospital of the Service shall comply with the provi15 sions of title XXIX of the Public Health Service Act.’’.

Æ