II 

★(Star Print) 

109TH CONGRESS 

1ST SESSION S. 71 

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

protection by establishing minimum nurse staffing ratios at certain Medicare providers, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

JANUARY 24, 2005 

Mr. INOUYE introduced the following bill; which was read twice and referred 

to the Committee on Finance 

A BILL 

To amend title XVIII of the Social Security Act to provide 

for patient protection by establishing minimum nurse 

staffing ratios at certain Medicare providers, and for 

other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Registered Nurse Safe 

5 Staffing Act of 2005’’. 

6 SEC. 2. FINDINGS. 

7 Congress makes the following findings: 
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1 (1) There are hospitals throughout the United 

2 States that have inadequate staffing of registered 

3 nurses to protect the well-being and health of the 

4 patients. 

5 (2) Studies show that the health of patients in 

6 hospitals is directly proportionate to the number of 

7 registered nurses working in the hospital. 

8 (3) There is a critical shortage of registered 

9 nurses in the United States. 

10 (4) The effect of that shortage is revealed in 

11 unsafe staffing levels in hospitals. 

12 (5) Patient safety is adversely affected by these 

13 unsafe staffing levels, creating a public health crisis. 

14 (6) Registered nurses are being required to per15 form professional services under conditions that do 

16 not support quality health care or a healthful work 

17 environment for registered nurses. 

18 (7) As a payer for inpatient and outpatient hos19 pital services for individuals entitled to benefits 

20 under the medicare program established under title 

21 XVIII of the Social Security Act, the Federal Gov22 ernment has a compelling interest in promoting the 

23 safety of such individuals by requiring any hospital 

24 participating in such program to establish minimum 

25 safe staffing levels for registered nurses. 
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1 SEC. 3. ESTABLISHMENT OF MINIMUM STAFFING RATIOS 

2 BY MEDICARE PARTICIPATING HOSPITALS. 

3 (a) REQUIREMENT OF MEDICARE PROVIDER AGREE4 MENT.—Section 1866(a)(1) of the Social Security Act (42 

5 U.S.C. 1395cc(a)(1)) is amended— 

6 (1) in subparagraph (R), by striking ‘‘and’’ 

7 after the comma at the end; 

8 (2) in subparagraph (S), by striking the period 

9 at the end and inserting ‘‘, and’’; and 

10 (3) by inserting after subparagraph (S) the fol11 lowing new subparagraph: 

12 ‘‘(T) in the case of a hospital, to meet the re13 quirements of section 1889.’’. 

14 (b) REQUIREMENTS.—Part D of title XVIII of the 

15 Social Security Act is amended by inserting after section 

16 1888 the following new section: 

17 ‘‘STAFFING REQUIREMENTS FOR MEDICARE

18 PARTICIPATING HOSPITALS

19 ‘‘SEC. 1889. (a) ESTABLISHMENT OF STAFFING SYS20 TEM.— 

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

22 shall adopt and implement a staffing system that en23 sures a number of registered nurses on each shift 

24 and in each unit of the hospital to ensure appro25 priate staffing levels for patient care. 
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1 ‘‘(2) STAFFING SYSTEM REQUIREMENTS.—Sub2 ject to paragraph (3), a staffing system adopted and 

3 implemented under this section shall— 

4 ‘‘(A) be based upon input from the direct 

5 care-giving registered nurse staff or their exclu6 sive representatives, as well as the chief nurse 

7 executive; 

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

9 and the level and variability of intensity of care 

10 to be provided, with appropriate consideration 

11 given to admissions, discharges, and transfers 

12 during each shift; 

13 ‘‘(C) account for contextual issues affect14 ing staffing and the delivery of care, including 

15 architecture and geography of the environment 

16 and available technology; 

17 ‘‘(D) reflect the level of preparation and 

18 experience of those providing care; 

19 ‘‘(E) account for staffing level effectiveness 

20 or deficiencies in related health care classifica21 tions, including but not limited to, certified 

22 nurse assistants, licensed vocational nurses, li23 censed psychiatric technicians, nursing assist24 ants, aides, and orderlies; 
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1 ‘‘(F) reflect staffing levels recommended by 

2 specialty nursing organizations; 

3 ‘‘(G) establish upwardly adjustable reg4 istered nurse-to-patient ratios based upon reg5 istered nurses’ assessment of patient acuity and 

6 existing conditions; 

7 ‘‘(H) provide that a registered nurse shall 

8 not be assigned to work in a particular unit 

9 without first having established the ability to 

10 provide professional care in such unit; and 

11 ‘‘(I) be based on methods that assure va12 lidity and reliability. 

13 ‘‘(3) LIMITATION.—A staffing system adopted 

14 and implemented under paragraph (1) may not— 

15 ‘‘(A) set registered-nurse levels below those 

16 required by any Federal or State law or regula17 tion; or 

18 ‘‘(B) utilize any minimum registered 

19 nurse-to-patient ratio established pursuant to 

20 paragraph (2)(G) as an upper limit on the 

21 staffing of the hospital to which such ratio ap22 plies. 

23 ‘‘(b) REPORTING, AND RELEASE TO PUBLIC, OF

24 CERTAIN STAFFING INFORMATION.— 
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1 ‘‘(1) REQUIREMENTS FOR HOSPITALS.—Each 

2 participating hospital shall— 

3 ‘‘(A) post daily for each shift, in a clearly 

4 visible place, a document that specifies in a uni5 form manner (as prescribed by the Secretary) 

6 the current number of licensed and unlicensed 

7 nursing staff directly responsible for patient 

8 care in each unit of the hospital, identifying 

9 specifically the number of registered nurses; 

10 ‘‘(B) upon request, make available to the 

11 public— 

12 ‘‘(i) the nursing staff information de13 scribed in subparagraph (A); and 

14 ‘‘(ii) a detailed written description of 

15 the staffing system established by the hos16 pital pursuant to subsection (a); and 

17 ‘‘(C) submit to the Secretary in a uniform 

18 manner (as prescribed by the Secretary) the 

19 nursing staff information described in subpara20 graph (A) through electronic data submission 

21 not less frequently than quarterly. 

22 ‘‘(2) SECRETARIAL RESPONSIBILITIES.—The 

23 Secretary shall— 

24 ‘‘(A) make the information submitted pur25 suant to paragraph (1)(C) publicly available, in-
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1 cluding by publication of such information on 

2 the Internet site of the Department of Health 

3 and Human Services; and 

4 ‘‘(B) provide for the auditing of such infor5 mation for accuracy as a part of the process of 

6 determining whether an institution is a hospital 

7 for purposes of this title. 

8 ‘‘(c) RECORDKEEPING; DATA COLLECTION; EVALUA9 TION.— 

10 ‘‘(1) RECORDKEEPING.—Each participating 

11 hospital shall maintain for a period of at least 3 

12 years (or, if longer, until the conclusion of pending 

13 enforcement activities) such records as the Secretary 

14 deems necessary to determine whether the hospital 

15 has adopted and implemented a staffing system pur16 suant to subsection (a). 

17 ‘‘(2) DATA COLLECTION ON CERTAIN OUT18 COMES.—The Secretary shall require the collection, 

19 maintenance, and submission of data by each par20 ticipating hospital sufficient to establish the link be21 tween the staffing system established pursuant to 

22 subsection (a) and— 

23 ‘‘(A) patient acuity from maintenance of 

24 acuity data through entries on patients’ charts; 
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1 ‘‘(B) patient outcomes that are nursing 

2 sensitive, such as patient falls, adverse drug 

3 events, injuries to patients, skin breakdown, 

4 pneumonia, infection rates, upper gastro5 intestinal bleeding, shock, cardiac arrest, length 

6 of stay, and patient readmissions; 

7 ‘‘(C) operational outcomes, such as work8 related injury or illness, vacancy and turnover 

9 rates, nursing care hours per patient day, on10 call use, overtime rates, and needle-stick inju11 ries; and 

12 ‘‘(D) patient complaints related to staffing 

13 levels. 

14 ‘‘(3) EVALUATION.—Each participating hospital 

15 shall annually evaluate its staffing system and estab16 lish minimum registered nurse staffing ratios to as17 sure ongoing reliability and validity of the system 

18 and ratios. The evaluation shall be conducted by a 

19 joint management-staff committee comprised of at 

20 least 50 percent of registered nurses who provide di21 rect patient care. 

22 ‘‘(d) ENFORCEMENT.— 

23 ‘‘(1) RESPONSIBILITY.—The Secretary shall en24 force the requirements and prohibitions of this sec-
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1 tion in accordance with the succeeding provisions of 

2 this subsection. 

3 ‘‘(2) PROCEDURES FOR RECEIVING AND INVES4 TIGATING COMPLAINTS.—The Secretary shall estab5 lish procedures under which— 

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

7 a participating hospital has violated a require8 ment or a prohibition of this section; and 

9 ‘‘(B) such complaints are investigated by 

10 the Secretary. 

11 ‘‘(3) REMEDIES.—If the Secretary determines 

12 that a participating hospital has violated a require13 ment of this section, the Secretary— 

14 ‘‘(A) shall require the facility to establish 

15 a corrective action plan to prevent the recur16 rence of such violation; and 

17 ‘‘(B) may impose civil money penalties 

18 under paragraph (4). 

19 ‘‘(4) CIVIL MONEY PENALTIES.— 

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

21 other penalties prescribed by law, the Secretary 

22 may impose a civil money penalty of not more 

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

24 requirement of this section, except that the Sec25 retary shall impose a civil money penalty of 
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1 more than $10,000 for each such violation in 

2 the case of a participating hospital that the 

3 Secretary determines has a pattern or practice 

4 of such violations (with the amount of such ad5 ditional penalties being determined in accord6 ance with a schedule or methodology specified 

7 in regulations). 

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

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

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

11 this paragraph in the same manner as such 

12 provisions apply to a penalty or proceeding 

13 under section 1128A. 

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

15 ‘‘(i) INTERNET SITE.—The Secretary 

16 shall publish on the Internet site of the 

17 Department of Health and Human Serv18 ices the names of participating hospitals on 

19 which civil money penalties have been im20 posed under this section, the violation for 

21 which the penalty was imposed, and such 

22 additional information as the Secretary de23 termines appropriate. 

24 ‘‘(ii) CHANGE OF OWNERSHIP.—With 

25 respect to a participating hospital that had 
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1 a change in ownership, as determined by 

2 the Secretary, penalties imposed on the hos3 pital while under previous ownership shall 

4 no longer be published by the Secretary of 

5 such Internet site after the 1-year period 

6 beginning on the date of change in owner7 ship. 

8 ‘‘(e) WHISTLEBLOWER PROTECTIONS.— 

9 ‘‘(1) PROHIBITION OF DISCRIMINATION AND

10 RETALIATION.—A participating hospital shall not 

11 discriminate or retaliate in any manner against any 

12 patient or employee of the hospital because that pa13 tient or employee, or any other person, has pre14 sented a grievance or complaint, or has initiated or 

15 cooperated in any investigation or proceeding of any 

16 kind, relating to the staffing system or other re17 quirements and prohibitions of this section. 

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

19 An employee of a participating hospital who has 

20 been discriminated or retaliated against in employ21 ment in violation of this subsection may initiate judi22 cial action in a United States district court and shall 

23 be entitled to reinstatement, reimbursement for lost 

24 wages, and work benefits caused by the unlawful 

25 acts of the employing hospital. Prevailing employees 
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1 are entitled to reasonable attorney’s fees and costs 

2 associated with pursuing the case. 

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

4 patient who has been discriminated or retaliated 

5 against in violation of this subsection may initiate 

6 judicial action in a United States district court. A 

7 prevailing patient shall be entitled to liquidated 

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

9 addition to any other damages under other applica10 ble statutes, regulations, or common law. Prevailing 

11 patients are entitled to reasonable attorney’s fees 

12 and costs associated with pursuing the case. 

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

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

15 years after the discrimination or retaliation with re16 spect to which the action is brought. 

17 ‘‘(5) TREATMENT OF ADVERSE EMPLOYMENT

18 ACTIONS.—For purposes of this subsection— 

19 ‘‘(A) an adverse employment action shall 

20 be treated as retaliation or discrimination; and 

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

22 includes— 

23 ‘‘(i) the failure to promote an indi24 vidual or provide any other employment-re-
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1 lated benefit for which the individual would 

2 otherwise be eligible; 

3 ‘‘(ii) an adverse evaluation or decision 

4 made in relation to accreditation, certifi5 cation, credentialing, or licensing of the in6 dividual; and 

7 ‘‘(iii) a personnel action that is ad8 verse to the individual concerned. 

9 ‘‘(f) RELATIONSHIP TO STATE LAWS.—Nothing in 

10 this section shall be construed as exempting or relieving 

11 any person from any liability, duty, penalty, or punish12 ment provided by any present or future law of any State 

13 or political subdivision of a State, other than any such 

14 law which purports to require or permit the doing of any 

15 act which would be an unlawful practice under this title. 

16 ‘‘(g) RELATIONSHIP TO CONDUCT PROHIBITED

17 UNDER THE NATIONAL LABOR RELATIONS ACT OR

18 OTHER COLLECTIVE BARGAINING LAWS.—Nothing in 

19 this section shall be construed as permitting conduct pro20 hibited under the National Labor Relations Act or under 

21 any other Federal, State, or local collective bargaining law. 

22 ‘‘(h) REGULATIONS.—The Secretary shall promul23 gate such regulations as are appropriate and necessary to 

24 implement this section. 

25 ‘‘(i) DEFINITIONS.—In this section: 
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1 ‘‘(1) PARTICIPATING HOSPITAL.—The term 

2 ‘participating hospital’ means a hospital that has en3 tered into a provider agreement under section 1866. 

4 ‘‘(2) REGISTERED NURSE.—The term ‘reg5 istered nurse’ means an individual who has been 

6 granted a license to practice as a registered nurse in 

7 at least 1 State. 

8 ‘‘(3) UNIT.—The term ‘unit’ of a hospital is an 

9 organizational department or separate geographic 

10 area of a hospital, such as a burn unit, a labor and 

11 delivery room, a post-anesthesia service area, an 

12 emergency department, an operating room, a pedi13 atric unit, a stepdown or intermediate care unit, a 

14 specialty care unit, a telemetry unit, a general med15 ical care unit, a subacute care unit, and a transi16 tional inpatient care unit. 

17 ‘‘(4) SHIFT.—The term ‘shift’ means a sched18 uled set of hours or duty period to be worked at a 

19 participating hospital. 

20 ‘‘(5) PERSON.—The term ‘person’ means 1 or 

21 more individuals, associations, corporations, unincor22 porated organizations, or labor unions.’’. 

23 (c) EFFECTIVE DATE.—The amendments made by 

24 this section shall take effect on January 1, 2006. 

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