II 

111TH CONGRESS 

2D SESSION S. 3491 

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

protection by establishing safe nurse staffing levels at certain Medicare 

providers, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

JUNE 15, 2010 

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 safe nurse staffing 

levels 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 2010’’. 

6 SEC. 2. FINDINGS. 

7 Congress makes the following findings: 


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1 (1) There are a number of hospitals throughout 

2 the United States that do not provide adequate reg3 istered nurse staffing to protect the health and safe4 ty of patients. 

5 (2) Research shows that patient safety in hos6 pitals is directly proportionate to the number of reg7 istered nurses working in the hospital. Higher staff8 ing levels by experienced registered nurses are re9 lated to lower rates of negative patient outcomes, in10 cluding falls, infections, medication errors, and even 

11 death. 

12 (3) Inadequate nurse staffing was found to be 

13 a contributing factor in 24 percent of all unantici14 pated events that resulted in patient death, injury, 

15 or permanent loss of function. 

16 (4) Registered nurses play a vital role in pre17 venting patient care errors, for example registered 

18 nurses intercepted 86 percent of medical errors be19 fore those errors affected patients. 

20 (5) As a payer for inpatient and outpatient hos21 pital services for individuals entitled to benefits 

22 under the Medicare program, the Federal Govern23 ment has a compelling interest in promoting the 

24 safety of such individuals by requiring any hospital 


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1 participating in that program to establish minimum 

2 safe staffing levels for registered nurses. 

3 (6) Adequate registered nurse staffing levels are 

4 necessary for the delivery of safe, quality care. Inad5 equate registered nurse staffing levels contribute to 

6 nurse burnout and exacerbate the current nursing 

7 shortage in the United States. 

8 (7) Nearly 25 percent of registered nurses indi9 cate that they are considering leaving direct patient 

10 care nursing due to inadequate nurse staffing, and 

11 nearly 60 percent of registered nurses report they 

12 know of another nurse who left direct care nursing 

13 because of concerns about inadequate nurse staffing. 

14 (8) The cost to a hospital to replace a direct 

15 patient care registered nurse is more than 101 per16 cent, and as much as 106 percent, of a registered 

17 nurse’s annual salary. 

18 (9) As a result of insufficient staff, registered 

19 nurses are being required to perform professional 

20 services under conditions that do not support quality 

21 health care or a healthful work environment for reg22 istered nurses. 


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1 SEC. 3. ESTABLISHMENT OF SAFE NURSE STAFFING LEV2 ELS BY MEDICARE PARTICIPATING HOS3 PITALS. 

4 (a) REQUIREMENT OF MEDICARE PROVIDER AGREE5 MENT.—Section 1866(a)(1) of the Social Security Act (42 

6 U.S.C. 1395cc(a)(1)) is amended— 

7 (1) in subparagraph (V), by striking ‘‘and’’ at 

8 the end; 

9 (2) in subparagraph (W), as added by section 

10 3005 of the Patient Protection and Affordable Care 

11 Act (Public Law 111–148)— 

12 (A) by moving such subparagraph 2 ems to 

13 the left; and 

14 (B) by striking the period at the end; 

15 (3) in subparagraph (W), as added by section 

16 6406(b) of the Patient Protection and Affordable 

17 Care Act (Public Law 111–148)— 

18 (A) by moving such subparagraph 2 ems to 

19 the left; 

20 (B) by redesignating such subparagraph as 

21 subparagraph (X); and 

22 (C) by striking the period at the end and 

23 inserting ‘‘, and’’; and 

24 (4) by inserting after subparagraph (X), as re25 designated by paragraph (3)(B), the following new 

26 subparagraph: 


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1 ‘‘(Y) in the case of a hospital (as defined in sec2 tion 1861(e)), to meet the requirements of section 

3 1899B.’’. 

4 (b) REQUIREMENTS.—Title XVIII of the Social Secu5 rity Act (42 U.S.C. 1395 et seq.), as amended by sections 

6 3022 and 3403 of the Patient Protection and Affordable 

7 Care Act (Public Law 111–148), is amended by inserting 

8 after section 1899A the following new section: 

9 ‘‘NURSE STAFFING REQUIREMENTS FOR MEDICARE

10 PARTICIPATING HOSPITALS

11 ‘‘SEC. 1899B. (a) IMPLEMENTATION OF NURSE

12 STAFFING PLAN.— 

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

14 shall implement a hospital-wide staffing plan for 

15 nursing services furnished in the hospital. 

16 ‘‘(2) REQUIREMENT FOR DEVELOPMENT OF

17 STAFFING PLAN BY HOSPITAL NURSE STAFFING

18 COMMITTEE.—The hospital-wide staffing plan for 

19 nursing services implemented by a hospital pursuant 

20 to paragraph (1)— 

21 ‘‘(A) shall be developed by the hospital 

22 nurse staffing committee established under sub23 section (b); and 

24 ‘‘(B) shall require that an appropriate 

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1 tient care in each unit and on each shift of the 

2 hospital to ensure staffing levels that— 

3 ‘‘(i) address the unique characteristics 

4 of the patients and hospital units; and 

5 ‘‘(ii) result in the delivery of safe, 

6 quality patient care, consistent with the re7 quirements under subsection (c). 

8 ‘‘(b) HOSPITAL NURSE STAFFING COMMITTEE.— 

9 ‘‘(1) ESTABLISHMENT.—Each participating 

10 hospital shall establish a hospital nurse staffing 

11 committee (hereinafter in this section referred to as 

12 the ‘Committee’). 

13 ‘‘(2) COMPOSITION.—A Committee established 

14 pursuant to this subsection shall be composed of 

15 members as follows: 

16 ‘‘(A) MINIMUM 55 PERCENT NURSE PAR17 TICIPATION.—Not less than 55 percent of the 

18 members of the Committee shall be registered 

19 nurses who provide direct patient care but who 

20 are neither hospital nurse managers nor part of 

21 the hospital administration staff. 

22 ‘‘(B) INCLUSION OF HOSPITAL NURSE

23 MANAGERS.—The Committee shall include 

24 members who are hospital nurse managers. 


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1 ‘‘(C) INCLUSION OF NURSES FROM SPE2 CIALTY UNITS.—The members of the Com3 mittee shall include at least 1 registered nurse 

4 who provides direct care from each nurse spe5 cialty or unit of the hospital (each such spe6 cialty or unit as determined by the hospital). 

7 ‘‘(D) OTHER HOSPITAL PERSONNEL.—The 

8 Committee shall include such other personnel of 

9 the hospital as the hospital determines to be ap10 propriate. 

11 ‘‘(3) DUTIES.— 

12 ‘‘(A) DEVELOPMENT OF STAFFING

13 PLAN.—The Committee shall develop a hospital14 wide staffing plan for nursing services furnished 

15 in the hospital consistent with the requirements 

16 under subsection (c). 

17 ‘‘(B) REVIEW AND MODIFICATION OF

18 STAFFING PLAN.—The Committee shall— 

19 ‘‘(i) conduct regular, ongoing moni20 toring of the implementation of the hos21 pital-wide staffing plan for nursing services 

22 furnished in the hospital; 

23 ‘‘(ii) carry out evaluations of the hos24 pital-wide staffing plan for nursing services 

25 at least annually; and 


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1 ‘‘(iii) make such modifications to the 

2 hospital-wide staffing plan for nursing 

3 services as may be appropriate. 

4 ‘‘(C) ADDITIONAL DUTIES.—The Com5 mittee shall— 

6 ‘‘(i) develop policies and procedures 

7 for overtime requirements of registered 

8 nurses providing direct patient care and 

9 for appropriate time and manner of relief 

10 of such registered nurses during routine 

11 absences; and 

12 ‘‘(ii) carry out such additional duties 

13 as the Committee determines to be appro14 priate. 

15 ‘‘(c) STAFFING PLAN REQUIREMENTS.— 

16 ‘‘(1) PLAN REQUIREMENTS.—Subject to para17 graph (2), a hospital-wide staffing plan for nursing 

18 services developed and implemented under this sec19 tion shall— 

20 ‘‘(A) be based upon input from the reg21 istered nurse staff of the hospital who provide 

22 direct patient care or their exclusive representa23 tives, as well as the chief nurse executive; 

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

25 and the level and variability of intensity of care 


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1 to be provided to those patients, with appro2 priate consideration given to admissions, dis3 charges, and transfers during each shift; 

4 ‘‘(C) take into account contextual issues 

5 affecting nurse staffing and the delivery of care, 

6 including architecture and geography of the en7 vironment and available technology; 

8 ‘‘(D) take into account the level of edu9 cation, training, and experience of those reg10 istered nurses providing direct patient care; 

11 ‘‘(E) take into account the staffing levels 

12 and services provided by other health care per13 sonnel associated with nursing care, such as 

14 certified nurse assistants, licensed vocational 

15 nurses, licensed psychiatric technicians, nursing 

16 assistants, aides, and orderlies; 

17 ‘‘(F) take into account staffing levels rec18 ommended by specialty nursing organizations; 

19 ‘‘(G) establish adjustable minimum num20 bers of registered nurses based upon an assess21 ment by registered nurses of the level and vari22 ability of intensity of care required by patients 

23 under existing conditions; 


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1 ‘‘(H) take into account unit and facility 

2 level staffing, quality and patient outcome data, 

3 and national comparisons, as available; 

4 ‘‘(I) ensure that a registered nurse shall 

5 not be assigned to work in a particular unit of 

6 the hospital without first having established the 

7 ability to provide professional care in such unit; 

8 and 

9 ‘‘(J) provide for exemptions from some or 

10 all requirements of the hospital-wide staffing 

11 plan for nursing services during a declared 

12 state of emergency (as defined in subsection 

13 (l)(1)) if the hospital is requested or expected 

14 to provide an exceptional level of emergency or 

15 other medical services. 

16 ‘‘(2) LIMITATION.—A staffing system developed 

17 and implemented under this section— 

18 ‘‘(A) shall not preempt any registered19 nurse staffing levels established under State law 

20 or regulation; and 

21 ‘‘(B) may not utilize any minimum number 

22 of registered nurses established under para23 graph (1)(G) as an upper limit on the nurse 

24 staffing of the hospital to which such minimum 

25 number applies. 


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1 ‘‘(d) REPORTING AND RELEASE TO PUBLIC OF CER2 TAIN STAFFING INFORMATION.— 

3 ‘‘(1) REQUIREMENTS FOR HOSPITALS.—Each 

4 participating hospital shall— 

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

6 visible place, a document that specifies in a uni7 form manner (as prescribed by the Secretary) 

8 the current number of licensed and unlicensed 

9 nursing staff directly responsible for patient 

10 care in each unit of the hospital, identifying 

11 specifically the number of registered nurses; 

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

13 public— 

14 ‘‘(i) the nursing staff information de15 scribed in subparagraph (A); 

16 ‘‘(ii) a detailed written description of 

17 the hospital-wide staffing plan imple18 mented by the hospital pursuant to sub19 section (a); and 

20 ‘‘(iii) not later than 90 days after the 

21 date on which an evaluation is carried out 

22 by the Committee under subsection 

23 (b)(3)(B)(ii), a copy of such evaluation; 

24 and 


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1 ‘‘(C) not less frequently than quarterly, 

2 submit to the Secretary in a uniform manner 

3 (as prescribed by the Secretary) the nursing 

4 staff information described in subparagraph (A) 

5 through electronic data submission. 

6 ‘‘(2) SECRETARIAL RESPONSIBILITIES.—The 

7 Secretary shall— 

8 ‘‘(A) make the information submitted pur9 suant to paragraph (1)(C) publicly available in 

10 a comprehensible format (as described in sub11 section (e)(2)(D)(ii)), including by publication 

12 on the Hospital Compare Internet Web site of 

13 the Department of Health and Human Services; 

14 and 

15 ‘‘(B) provide for the auditing of such infor16 mation for accuracy as a part of the process of 

17 determining whether the participating hospital 

18 is in compliance with the conditions of its 

19 agreement with the Secretary under section 

20 1866, including under subsection (a)(1)(Y) of 

21 such section. 

22 ‘‘(e) RECORDKEEPING; COLLECTION AND REPORT23 ING OF QUALITY DATA; EVALUATION.— 

24 ‘‘(1) RECORDKEEPING.—Each participating 

25 hospital shall maintain for a period of at least 3 


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1 years (or, if longer, until the conclusion of any pend2 ing enforcement activities) such records as the Sec3 retary deems necessary to determine whether the 

4 hospital has implemented a hospital-wide staffing 

5 plan for nursing services pursuant to subsection (a). 

6 ‘‘(2) COLLECTION AND REPORTING OF QUALITY

7 DATA ON NURSING SERVICES.— 

8 ‘‘(A) IN GENERAL.—The Secretary shall 

9 require the collection, aggregation, mainte10 nance, and reporting of quality data relating to 

11 nursing services furnished by each participating 

12 hospital. 

13 ‘‘(B) USE OF ENDORSED MEASURES.—In 

14 carrying out this paragraph, the Secretary shall 

15 use only quality measures for nursing-sensitive 

16 care that are endorsed by the consensus-based 

17 entity with a contract under section 1890(a). 

18 ‘‘(C) USE OF QUALIFIED THIRD PARTY EN19 TITIES FOR COLLECTION AND SUBMISSION OF

20 DATA.— 

21 ‘‘(i) IN GENERAL.—A participating 

22 hospital may enter into agreements with 

23 third party entities that have demonstrated 

24 expertise in the collection and submission 

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1 lect, aggregate, maintain, and report the 

2 quality data of the hospital pursuant to 

3 subparagraph (A). 

4 ‘‘(ii) CONSTRUCTION.—Nothing in 

5 clause (i) shall be construed to excuse or 

6 exempt a participating hospital that has 

7 entered into an agreement described in 

8 such clause from compliance with require9 ments for quality data collection, aggrega10 tion, maintenance, and reporting imposed 

11 under this paragraph. 

12 ‘‘(D) REPORTING OF QUALITY DATA.— 

13 ‘‘(i) PUBLICATION ON HOSPITAL COM14 PARE WEB SITE.—Subject to the suc15 ceeding provisions of this subparagraph, 

16 the Secretary shall make the data sub17 mitted pursuant to subparagraph (A) pub18 licly available, including by publication on 

19 the Hospital Compare Internet Web site of 

20 the Department of Health and Human 

21 Services. 

22 ‘‘(ii) COMPREHENSIBLE FORMAT.— 

23 Data made available to the public under 

24 clause (i) shall be presented in a clearly 

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1 sumers of hospital services to make mean2 ingful comparisons among hospitals, in3 cluding concise explanations in plain 

4 English of how to interpret the data, of the 

5 difference in types of nursing staff, of the 

6 relationship between nurse staffing levels 

7 and quality of care, and of how nurse 

8 staffing may vary based on patient case 

9 mix. 

10 ‘‘(iii) OPPORTUNITY TO CORRECT ER11 RORS.—The Secretary shall establish a 

12 process under which participating hospitals 

13 may review data submitted to the Sec14 retary pursuant to subparagraph (A) to 

15 correct errors, if any, contained in that 

16 data submission before making the data 

17 available to the public under clause (i). 

18 ‘‘(3) EVALUATION OF DATA.—The Secretary 

19 shall provide for the analysis of quality data col20 lected from participating hospitals under paragraph 

21 (2) in order to evaluate the effect of hospital-wide 

22 staffing plans for nursing services implemented pur23 suant to subsection (a) on— 

24 ‘‘(A) patient outcomes that are nursing 

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1 rence, falls resulting in injury, length of stay, 

2 and central line catheter infections); and 

3 ‘‘(B) nursing workforce safety and reten4 tion (including work-related injury, staff skill 

5 mix, nursing care hours per patient day, va6 cancy and voluntary turnover rates, overtime 

7 rates, use of temporary agency personnel, and 

8 nurse satisfaction). 

9 ‘‘(f) REFUSAL OF ASSIGNMENT.—A nurse may refuse 

10 to accept an assignment as a nurse in a participating hos11 pital, or in a unit of a participating hospital, if— 

12 ‘‘(1) the assignment is in violation of the hos13 pital-wide staffing plan for nursing services imple14 mented pursuant to subsection (a); or 

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

16 training, or experience to fulfill the assignment with17 out compromising the safety of any patient or jeop18 ardizing the license of the nurse. 

19 ‘‘(g) ENFORCEMENT.— 

20 ‘‘(1) RESPONSIBILITY.—The Secretary shall en21 force the requirements and prohibitions of this sec22 tion in accordance with the succeeding provisions of 

23 this subsection. 


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1 ‘‘(2) PROCEDURES FOR RECEIVING AND INVES2 TIGATING COMPLAINTS.—The Secretary shall estab3 lish procedures under which— 

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

5 a participating hospital has violated a require6 ment of or a prohibition under this section; and 

7 ‘‘(B) such complaints are investigated by 

8 the Secretary. 

9 ‘‘(3) REMEDIES.—Except as provided in para10 graph (5), if the Secretary determines that a partici11 pating hospital has violated a requirement of this 

12 section, the Secretary— 

13 ‘‘(A) shall require the hospital to establish 

14 a corrective action plan to prevent the recur15 rence of such violation; and 

16 ‘‘(B) may impose civil money penalties 

17 under paragraph (4). 

18 ‘‘(4) CIVIL MONEY PENALTIES.— 

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

20 other penalties prescribed by law, the Secretary 

21 may impose a civil money penalty of not more 

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

23 requirement of this section, except that the Sec24 retary shall impose a civil money penalty of 

25 more than $10,000 for each such violation in 


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1 the case of a participating hospital that the 

2 Secretary determines has a pattern or practice 

3 of such violations (with the amount of such ad4 ditional penalties being determined in accord5 ance with a schedule or methodology specified 

6 in regulations). 

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

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

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

10 this paragraph in the same manner as such 

11 provisions apply to a penalty or proceeding 

12 under section 1128A. 

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

14 ‘‘(i) INTERNET WEB SITE.—The Sec15 retary shall publish on an appropriate 

16 Internet Web site of the Department of 

17 Health and Human Services the names of 

18 participating hospitals on which civil 

19 money penalties have been imposed under 

20 this section, the violation for which the 

21 penalty was imposed, and such additional 

22 information as the Secretary determines 

23 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 

3 hospital while under previous ownership 

4 shall no longer be published by the Sec5 retary of such Internet Web site after the 

6 1-year period beginning on the date of the 

7 change in ownership. 

8 ‘‘(5) PENALTY FOR FAILURE TO COLLECT AND

9 REPORT QUALITY DATA ON NURSING SERVICES.— 

10 ‘‘(A) IN GENERAL.—In the case of a par11 ticipating hospital that fails to comply with re12 quirements under subsection (e)(2) to collect, 

13 aggregate, maintain, and report quality data re14 lating to nursing services furnished by the hos15 pital, instead of the remedies described in para16 graph (3), the provisions of subparagraph (B) 

17 shall apply with respect to each such failure of 

18 the participating hospital. 

19 ‘‘(B) PENALTY.—In the case of a failure 

20 by a participating hospital to comply with the 

21 requirements under subsection (e)(2) for a year, 

22 each such failure shall be deemed to be a failure 

23 to submit data required under section 

24 1833(t)(17)(A), section 1886(b)(3)(B)(viii), 

25 section 1886(j)(7)(A), or section 


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1 1886(m)(5)(A), as the case may be, with re2 spect to the participating hospital involved for 

3 that year. 

4 ‘‘(h) WHISTLEBLOWER PROTECTIONS.— 

5 ‘‘(1) PROHIBITION OF DISCRIMINATION AND

6 RETALIATION.—A participating hospital shall not 

7 discriminate or retaliate in any manner against any 

8 patient or employee of the hospital because that pa9 tient or employee, or any other person, has pre10 sented a grievance or complaint, or has initiated or 

11 cooperated in any investigation or proceeding of any 

12 kind, relating to— 

13 ‘‘(A) the hospital-wide staffing plan for 

14 nursing services developed and implemented 

15 under this section; or 

16 ‘‘(B) any right, other requirement or pro17 hibition under this section, including a refusal 

18 to accept an assignment described in subsection 

19 (f). 

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

21 An employee of a participating hospital who has 

22 been discriminated or retaliated against in employ23 ment in violation of this subsection may initiate judi24 cial action in a United States district court and shall 

25 be entitled to reinstatement, reimbursement for lost 


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1 wages, and work benefits caused by the unlawful 

2 acts of the employing hospital. Prevailing employees 

3 are entitled to reasonable attorney’s fees and costs 

4 associated with pursuing the case. 

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

6 patient who has been discriminated or retaliated 

7 against in violation of this subsection may initiate 

8 judicial action in a United States district court. A 

9 prevailing patient shall be entitled to liquidated 

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

11 addition to any other damages under other applica12 ble statutes, regulations, or common law. Prevailing 

13 patients are entitled to reasonable attorney’s fees 

14 and costs associated with pursuing the case. 

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

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

17 years after the discrimination or retaliation with re18 spect to which the action is brought. 

19 ‘‘(5) TREATMENT OF ADVERSE EMPLOYMENT

20 ACTIONS.—For purposes of this subsection— 

21 ‘‘(A) an adverse employment action shall 

22 be treated as discrimination or retaliation; and 

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

24 includes— 


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1 ‘‘(i) the failure to promote an indi2 vidual or provide any other employment-re3 lated benefit for which the individual would 

4 otherwise be eligible; 

5 ‘‘(ii) an adverse evaluation or decision 

6 made in relation to accreditation, certifi7 cation, credentialing, or licensing of the in8 dividual; and 

9 ‘‘(iii) a personnel action that is ad10 verse to the individual concerned. 

11 ‘‘(i) RELATIONSHIP TO STATE LAWS.—Nothing in 

12 this section shall be construed as exempting or relieving 

13 any person from any liability, duty, penalty, or punish14 ment provided by the law of any State or political subdivi15 sion of a State, other than any such law which purports 

16 to require or permit any action prohibited under this title. 

17 ‘‘(j) RELATIONSHIP TO CONDUCT PROHIBITED

18 UNDER THE NATIONAL LABOR RELATIONS ACT OR

19 OTHER COLLECTIVE BARGAINING LAWS.—Nothing in 

20 this section shall be construed as— 

21 ‘‘(1) permitting conduct prohibited under the 

22 National Labor Relations Act or under any other 

23 Federal, State, or local collective bargaining law; or 


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1 ‘‘(2) preempting, limiting, or modifying a collec2 tive bargaining agreement entered into by a partici3 pating hospital. 

4 ‘‘(k) REGULATIONS.— 

5 ‘‘(1) IN GENERAL.—The Secretary shall pro6 mulgate such regulations as are appropriate and 

7 necessary to implement this section. 

8 ‘‘(2) IMPLEMENTATION.— 

9 ‘‘(A) IN GENERAL.—Except as provided in 

10 subparagraph (B), as soon as practicable but 

11 not later than 2 years after the date of the en12 actment of this section, a participating hospital 

13 shall have implemented a hospital-wide staffing 

14 plan for nursing services under this section. 

15 ‘‘(B) SPECIAL RULE FOR RURAL HOS16 PITALS.—In the case of a participating hospital 

17 located in a rural area (as defined in section 

18 1886(d)(2)(D)), such participating hospital 

19 shall have implemented a hospital-wide staffing 

20 plan for nursing services under this section as 

21 soon as practicable but not later than 4 years 

22 after the date of the enactment of this section. 

23 ‘‘(l) DEFINITIONS.—In this section: 

24 ‘‘(1) DECLARED STATE OF EMERGENCY.—The 

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1 cially designated state of emergency that has been 

2 declared by the Federal Government or the head of 

3 the appropriate State or local governmental agency 

4 having authority to declare that the State, county, 

5 municipality, or locality is in a state of emergency, 

6 but does not include a state of emergency that re7 sults from a labor dispute in the health care indus8 try or consistent understaffing. 

9 ‘‘(2) PARTICIPATING HOSPITAL.—The term 

10 ‘participating hospital’ means a hospital (as defined 

11 in section 1861(e)) that has entered into a provider 

12 agreement under section 1866. 

13 ‘‘(3) PERSON.—The term ‘person’ means one or 

14 more individuals, associations, corporations, unincor15 porated organizations, or labor unions. 

16 ‘‘(4) REGISTERED NURSE.—The term ‘reg17 istered nurse’ means an individual who has been 

18 granted a license to practice as a registered nurse in 

19 at least 1 State. 

20 ‘‘(5) SHIFT.—The term ‘shift’ means a sched21 uled set of hours or duty period to be worked at a 

22 participating hospital. 

23 ‘‘(6) UNIT.—The term ‘unit’ means, with re24 spect to a hospital, an organizational department or 

25 separate geographic area of a hospital, including a 


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1 burn unit, a labor and delivery room, a post-anes2 thesia service area, an emergency department, an 

3 operating room, a pediatric unit, a stepdown or in4 termediate care unit, a specialty care unit, a telem5 etry unit, a general medical care unit, a subacute 

6 care unit, and a transitional inpatient care unit.’’. 

Æ 


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