I 

108TH CONGRESS 

1ST SESSION H. R. 745

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 HOUSE OF REPRESENTATIVES 

FEBRUARY 12, 2003

Mr. STARK (for himself, Mr. LATOURETTE, Mr. RANGEL, Mr. KLECZKA, Mr. 

WAXMAN, Mr. PALLONE, Ms. DEGETTE, Mr. SERRANO, Mr. SIMMONS, 

Mr. TOWNS, Mr. WEINER, Ms. LEE, Ms. LOFGREN, Ms. SCHAKOWSKY, 

Mr. MOORE, Ms. NORTON, Ms. WOOLSEY, Mr. FROST, Mr. OWENS, Mr. 

KILDEE, Ms. DELAURO, Mr. SANDERS, Mrs. CHRISTENSEN, Mr. 

GRIJALVA, Mr. LYNCH, Mr. FRANK of Massachusetts, Mr. LANGEVIN, 

Mrs. CAPPS, Mr. MEEHAN, Mr. FILNER, Mr. HINCHEY, Mr. INSLEE, Mr. 

MCDERMOTT, Mr. WEXLER, Mr. NADLER, Mr. GORDON, Mr. BISHOP of 

New York, Mr. GUTIERREZ, Mr. SANDLIN, Ms. KILPATRICK, Mr. 

CARDIN, Mr. ANDREWS, Mr. CARSON of Oklahoma, Mr. DAVIS of Illinois, 

Mr. KUCINICH, and Mr. HOLT) 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 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.
2

•HR 745 IH 

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 2003’’.

6 SEC. 2. FINDINGS. 

7 The Congress finds as follows: 

8 (1) The Federal Government has a substantial 

9 interest in assuring that delivery of health care serv10 ices to patients in health care facilities is adequate 

11 and safe. 

12 (2) Research, including a recent study pub13 lished in the October 23–30, 2002 issue of the Jour14 nal of the American Medical Association (JAMA), 

15 documents that higher nurse staffing levels result in 

16 better patient outcomes, yet health care providers re17 port substantial difficulties in recruiting and retain18 ing sufficient nursing staff, as evidenced by the ap19 proximately 500,000 licensed nurses who are not 

20 practicing nursing. 

21 (3) While job dissatisfaction and overtime work 

22 are contributing to the departure of nurses from 

23 their profession, as highlighted by a recent report of 

24 the Comptroller General of the United States, health 
3

•HR 745 IH 

1 care providers continue to make use of mandatory 

2 overtime as a staffing method. 

3 (4) The widespread practice of requiring nurses 

4 to work extended shifts and forego days off causes 

5 nurses to frequently provide care in a state of fa6 tigue, contributing to medical errors and other con7 sequences that compromise patient safety. 

8 (5) Limitations on mandatory overtime will en9 sure that health care facilities throughout the coun10 try operate in a manner that safeguards public safe11 ty and guarantees the delivery of quality health care 

12 services and facilitates the retention and recruitment 

13 of nurses. 

14 SEC. 3. LIMITATIONS ON MANDATORY OVERTIME FOR 

15 NURSES. 

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

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

18 (1) in subsection (a)(1)—

19 (A) in subparagraph (R), by striking 

20 ‘‘and’’ at the end; 

21 (B) in subparagraph (S), by striking the 

22 period and inserting ‘‘, and’’; and 

23 (C) by inserting after subparagraph (S), 

24 the following: 
4

•HR 745 IH 

1 ‘‘(T) to comply with the requirements of sub2 section (j) (relating to limitations on mandatory 

3 overtime for nurses).’’; and 

4 (2) by adding at the end the following new sub5 section: 

6 ‘‘(j) LIMITATIONS ON MANDATORY OVERTIME FOR

7 NURSES.—For purposes of subsection (a)(1)(T), the re8 quirements of this subsection are the following: 

9 ‘‘(1) PROHIBITION ON MANDATORY OVER10 TIME.—Except as provided in this subsection, a pro11 vider of services shall not, directly or indirectly, re12 quire a nurse to work in excess of any of the fol13 lowing: 

14 ‘‘(A) The scheduled work shift or duty pe15 riod of the nurse. 

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

17 ‘‘(C) 80 hours in a consecutive 14-day pe18 riod. 

19 ‘‘(2) EXCEPTIONS.—

20 ‘‘(A) IN GENERAL.—Subject to subpara21 graph (B), the requirements of paragraph (1) 

22 shall not apply to a provider of services during 

23 a declared state of emergency if the provider is 

24 requested, or otherwise is expected, to provide 
5

•HR 745 IH 

1 an exceptional level of emergency or other med2 ical services to the community. 

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

4 provider of services to which subparagraph (A) 

5 applies, a nurse may only be required to work 

6 for periods in excess of the periods described in 

7 paragraph (1) if—

8 ‘‘(i) the provider has made reasonable 

9 efforts to fill the immediate staffing needs 

10 of the provider through alternative means; 

11 and 

12 ‘‘(ii) the duration of the work require13 ment does not extend past the earlier of—

14 ‘‘(I) the date on which the de15 clared state of emergency ends; or 

16 ‘‘(II) the date on which the pro17 vider’s direct role in responding to the 

18 medical needs resulting from the de19 clared state of emergency ends. 

20 ‘‘(3) REPORT OF VIOLATIONS.—

21 ‘‘(A) RIGHT TO REPORT.—

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

23 complaint with the Secretary against a 

24 provider of services who violates the provi25 sions of this subsection. 
6

•HR 745 IH 

1 ‘‘(ii) PROCEDURE.—The Secretary 

2 shall establish a procedure under which a 

3 nurse may file a complaint under clause 

4 (i). 

5 ‘‘(B) INVESTIGATION OF COMPLAINT.—

6 The Secretary shall investigate complaints of 

7 violations filed by a nurse under subparagraph 

8 (A).

9 ‘‘(C) ACTIONS.—If the Secretary deter10 mines that a provider of services has violated 

11 the provisions of this subsection, the Secretary 

12 shall require the provider to establish a plan of 

13 action to eliminate the occurrence of such viola14 tion, and may seek civil money penalties under 

15 paragraph (7). 

16 ‘‘(4) NURSE NONDISCRIMINATION PROTEC17 TIONS.—

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

19 shall not penalize, discriminate, or retaliate in 

20 any manner with respect to any aspect of em21 ployment, including discharge, promotion, com22 pensation, or terms, conditions, or privileges of 

23 employment against a nurse who refuses to 

24 work mandatory overtime or who in good faith, 
7

•HR 745 IH 

1 individually or in conjunction with another per2 son or persons—

3 ‘‘(i) reports a violation or suspected 

4 violation of this subsection to a public reg5 ulatory agency, a private accreditation 

6 body, or the management personnel of the 

7 provider of services; 

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

9 participates in an investigation or pro10 ceeding brought by a regulatory agency or 

11 private accreditation body concerning mat12 ters covered by this subsection; or 

13 ‘‘(iii) informs or discusses with other 

14 employees, with representatives of those 

15 employees, or with representatives of asso16 ciations of health care professionals, viola17 tions or suspected violations of this sub18 section. 

19 ‘‘(B) RETALIATORY REPORTING.—A pro20 vider of services may not file a complaint or a 

21 report against a nurse with the appropriate 

22 State professional disciplinary agency because 

23 the nurse refused to comply with a request to 

24 work mandatory overtime. 
8

•HR 745 IH 

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

2 paragraph, a nurse is deemed to be acting in 

3 good faith if the nurse reasonably believes—

4 ‘‘(i) that the information reported or 

5 disclosed is true; and 

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

7 may occur. 

8 ‘‘(5) NOTICE.—

9 ‘‘(A) REQUIREMENT TO POST NOTICE.—

10 Each provider of services shall post conspicu11 ously in an appropriate location a sign (in a 

12 form specified by the Secretary) specifying 

13 rights of nurses under this section. 

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

15 sign shall include a statement that a nurse may 

16 file a complaint with the Secretary against a 

17 provider of services who violates the provisions 

18 of this subsection and information with respect 

19 to the manner of filing such a complaint. 

20 ‘‘(6) POSTING OF NURSE SCHEDULES.—A pro21 vider of services shall regularly post in a conspicuous 

22 manner the nurse schedules (for such periods of 

23 time that the Secretary determines appropriate by 

24 type or class of provider of services) for the depart25 ment or unit involved, and shall make available upon 
9

•HR 745 IH 

1 request to nurses assigned to the department or unit 

2 the daily nurse schedule for such department or 

3 unit. 

4 ‘‘(7) CIVIL MONEY PENALTY.—

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

6 impose a civil money penalty of not more than 

7 $10,000 for each knowing violation of the provi8 sions of this subsection committed by a provider 

9 of services. 

10 ‘‘(B) PATTERNS OF VIOLATIONS.—Not11 withstanding subparagraph (A), the Secretary 

12 shall provide for the imposition of more severe 

13 civil money penalties under this paragraph for 

14 providers of services that establish patterns of 

15 repeated violations of such provisions. 

16 ‘‘(C) ADMINISTRATION OF PENALTIES.—

17 The provisions of section 1128A (other than 

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

19 money penalty under this paragraph in the 

20 same manner as such provisions apply to a pen21 alty or proceeding under section 1128A(a). 

22 The Secretary shall publish on the Internet site of 

23 the Department of Health and Human Services the 

24 names of providers of services against which civil 

25 money penalties have been imposed under this para-
10

•HR 745 IH 

1 graph, the violation for which the penalty was im2 posed, and such additional information as the Sec3 retary determines appropriate. With respect to a 

4 provider of services that has had a change in owner5 ship, as determined by the Secretary, penalties im6 posed on the provider of services while under pre7 vious ownership shall no longer be published by the 

8 Secretary on such Internet site after the 1-year pe9 riod beginning on the date of change in ownership. 

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

11 this subsection shall be construed as precluding a 

12 nurse from voluntarily working more than any of the 

13 periods of time described in paragraph (1) so long 

14 as such work is done consistent with professional 

15 standards of safe patient care. 

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

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

18 ‘mandatory overtime’ means hours worked in 

19 excess of the periods of time described in para20 graph (1), except as provided in paragraph (2), 

21 pursuant to any request made by a provider of 

22 services to a nurse which, if refused or declined 

23 by the nurse involved, may result in an adverse 

24 employment consequence to the nurse, including 

25 discharge, discipline, loss of promotion, or retal-
11

•HR 745 IH 

1 iatory reporting of the nurse to the State pro2 fessional disciplinary agency involved. 

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

4 means time worked in excess of the periods of 

5 time described in paragraph (1). 

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

7 registered nurse or a licensed practical nurse. 

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

9 ‘provider of services’ means—

10 ‘‘(i) a hospital, 

11 ‘‘(ii) a hospital outpatient department, 

12 ‘‘(iii) a critical access hospital, 

13 ‘‘(iv) an ambulatory surgical center, 

14 ‘‘(v) a home health agency, 

15 ‘‘(vi) a rehabilitation agency, 

16 ‘‘(vii) a clinic, including a rural health 

17 clinic, or 

18 ‘‘(viii) a Federally qualified health 

19 center. 

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

21 The term ‘declared state of emergency’ means 

22 an officially designated state of emergency that 

23 has been declared by the Federal Government 

24 or the head of the appropriate State or local 

25 governmental agency having authority to de-
12

•HR 745 IH 

1 clare that the State, county, municipality, or lo2 cality is in a state of emergency, but does not 

3 include a state of emergency that results from 

4 a labor dispute in the health care industry or 

5 consistent understaffing. 

6 ‘‘(F) STANDARDS OF SAFE PATIENT

7 CARE.—The term ‘standards of safe patient 

8 care’ means the recognized professional stand9 ards governing the profession of the nurse in10 volved.’’.

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

12 this section shall take effect 1 year after the date of enact13 ment of this Act. 

14 SEC. 4. REPORTS. 

15 (a) STANDARDS ON SAFE WORKING HOURS FOR

16 NURSES.—

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

18 Human Services, acting through the Director of the 

19 Agency for Healthcare Research and Quality, shall 

20 conduct a study to establish appropriate standards 

21 for the maximum number of hours that a nurse, who 

22 furnishes health care to patients, may work without 

23 compromising the safety of such patients. Such 

24 standards may vary by provider of service and by de25 partment within a provider of services, by duties or 
13

•HR 745 IH 

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

2 other factors that the Director determines appro3 priate. The Director may contract with an eligible 

4 entity or organization to carry out the study under 

5 this paragraph. 

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

7 date of the enactment of this Act, the Secretary 

8 shall submit to Congress a report on the study con9 ducted under paragraph (1), and shall include rec10 ommendations for such appropriate standards of 

11 maximum work hours. 

12 (b) REPORT ON MANDATORY OVERTIME IN FEDER13 ALLY OPERATED MEDICAL FACILITIES.—

14 (1) STUDY.—

15 (A) IN GENERAL.—The Director of the Of16 fice of Management and Budget shall conduct 

17 a study to determine the extent to which feder18 ally operated medical facilities have in effect 

19 practices and policies with respect to overtime 

20 requirements for nurses that are inconsistent 

21 with the provisions of section 1866(j) of the So22 cial Security Act, as added by section 3. 

23 (B) FEDERALLY OPERATED MEDICAL FA24 CILITIES DEFINED.—In this subsection, the 

25 term ‘‘federally operated medical facilities’’ 
14

•HR 745 IH 

1 means acute care hospitals, freestanding clinics, 

2 and home health care clinics that are operated 

3 by the Department of Veterans Affairs, the De4 partment of Defense, or any other department 

5 or agency of the United States. 

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

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

8 of the Office of Management and Budget shall sub9 mit to Congress a report on the study conducted 

10 under paragraph (1) and shall include recommenda11 tions for the implementation of policies within feder12 ally operated medical facilities with respect to over13 time requirements for nurses that are consistent 

14 with such section 1866(j), as so added.

Æ