I 

117TH CONGRESS 

1ST SESSION H. R. 3165 

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 12, 2021 

Ms. SCHAKOWSKY (for herself, Mr. RUSH, Mr. KHANNA, Mr. COHEN, Mr. 

TAKANO, Ms. MOORE of Wisconsin, Ms. LEE of California, Ms. 

VELA ́ZQUEZ, Mr. BLUMENAUER, Mr. SHERMAN, Ms. JAYAPAL, and Ms. 

LOFGREN) 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, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS; FINDINGS. 

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

5 ‘‘Nurse Staffing Standards for Hospital Patient Safety 

6 and Quality Care Act of 2021’’. 


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1 (b) TABLE OF CONTENTS.—The table of contents for 

2 this Act is as follows: 

Sec. 1. Short title; table of contents; findings. 

Sec. 2. Minimum direct care registered nurse staffing requirement. 

Sec. 3. Enforcement of requirements through Federal programs. 

Sec. 4. Nurse workforce initiative. 

3 (c) FINDINGS.—Congress finds the following: 

4 (1) The Federal Government has a substantial 

5 interest in promoting quality care and improving the 

6 delivery of health care services to patients in health 

7 care facilities in the United States. 

8 (2) Recent changes in health care delivery sys9 tems that have resulted in higher acuity levels 

10 among patients in health care facilities increase the 

11 need for improved quality measures in order to pro12 tect patient care and reduce the incidence of medical 

13 errors. 

14 (3) Inadequate and poorly monitored registered 

15 nurse staffing practices that result in too few reg16 istered nurses providing direct care jeopardize the 

17 delivery of quality health care services. 

18 (4) Numerous studies have shown that patient 

19 outcomes are directly correlated to direct care reg20 istered nurse staffing levels, including a 2010 

21 Health Services Research study that concluded that 

22 implementation of minimum nurse-to-patient staff23 ing ratios in California has led to improved patient 


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1 outcomes and nurse retention and a 2014 Agency 

2 for Healthcare Research and Quality study that con3 cluded increases in nurse staffing and skill mix lead 

4 to improved quality and reduced length of stay at no 

5 additional cost. 

6 (5) Requirements for direct care registered 

7 nurse staffing ratios will help address the registered 

8 nurse shortage in the United States by aiding in re9 cruitment of new registered nurses and improving 

10 retention of registered nurses who are considering 

11 leaving direct patient care because of demands cre12 ated by inadequate staffing. 

13 (6) Establishing adequate minimum direct care 

14 registered nurse-to-patient ratios that take into ac15 count patient acuity measures will improve the deliv16 ery of quality health care services and guarantee pa17 tient safety. 

18 (7) Establishing safe staffing standards for di19 rect care registered nurses is a critical component of 

20 assuring that there is adequate hospital staffing at 

21 all levels to improve the delivery of quality care and 

22 protect patient safety. 


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1 SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE 

2 STAFFING REQUIREMENT. 

3 (a) MINIMUM DIRECT CARE REGISTERED NURSE

4 STAFFING REQUIREMENTS.—The Public Health Service 

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

6 end the following new title: 

7 ‘‘TITLE XXXIV—MINIMUM DI8 RECT CARE REGISTERED 

9 NURSE STAFFING REQUIRE10 MENT 

11 ‘‘SEC. 3401. MINIMUM NURSE STAFFING REQUIREMENT. 

12 ‘‘(a) STAFFING PLAN.— 

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

14 a staffing plan that— 

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

16 quality delivery of health care services and pro17 tects patient safety; and 

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

19 this title. 

20 ‘‘(2) EFFECTIVE DATES.— 

21 ‘‘(A) IMPLEMENTATION OF STAFFING

22 PLAN.—Subject to subparagraph (B), the re23 quirements under paragraph (1) shall take ef24 fect on a date to be determined by the Sec25 retary, but not later than 1 year after the date 

26 of the enactment of this title. 


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1 ‘‘(B) APPLICATION OF MINIMUM DIRECT

2 CARE REGISTERED NURSE-TO-PATIENT RA3 TIOS.—The requirements under subsection (b) 

4 shall take effect as soon as practicable, as de5 termined by the Secretary, but not later than— 

6 ‘‘(i) 2 years after the date of enact7 ment of this title; and 

8 ‘‘(ii) in the case of a hospital in a 

9 rural area (as defined in section 

10 1886(d)(2)(D) of the Social Security Act), 

11 4 years after the date of enactment of this 

12 title. 

13 ‘‘(b) MINIMUM DIRECT CARE REGISTERED NURSE14 TO-PATIENT RATIOS.— 

15 ‘‘(1) IN GENERAL.—Except as provided in para16 graph (4) and other provisions of this section, a hos17 pital’s staffing plan shall provide that, at all times 

18 during each shift within a unit of the hospital, and 

19 with a full complement of ancillary and support 

20 staff, a direct care registered nurse may be assigned 

21 to not more than the following number of patients 

22 in that unit: 

23 ‘‘(A) One patient in trauma emergency 

24 units. 


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1 ‘‘(B) One patient in operating room units, 

2 provided that a minimum of 1 additional person 

3 serves as a scrub assistant in such unit. 

4 ‘‘(C) Two patients in critical care units, in5 cluding neonatal intensive care units, emer6 gency critical care and intensive care units, 

7 labor and delivery units, coronary care units, 

8 acute respiratory care units, postanesthesia 

9 units, and burn units. 

10 ‘‘(D) Three patients in emergency room 

11 units, pediatrics units, stepdown units, telem12 etry units, antepartum units, and combined 

13 labor, deliver, and postpartum units. 

14 ‘‘(E) Four patients in medical-surgical 

15 units, intermediate care nursery units, acute 

16 care psychiatric units, and other specialty care 

17 units. 

18 ‘‘(F) Five patients in rehabilitation units 

19 and skilled nursing units. 

20 ‘‘(G) Six patients in postpartum (3 cou21 plets) units and well-baby nursery units. 

22 ‘‘(2) SIMILAR UNITS WITH DIFFERENT

23 NAMES.—The Secretary may apply minimum direct 

24 care registered nurse-to-patient ratios established in 

25 paragraph (1) for a hospital unit referred to in such 


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1 paragraph to a type of hospital unit not referred to 

2 in such paragraph if such type of hospital unit pro3 vides a level of care to patients whose needs are 

4 similar to the needs of patients cared for in the hos5 pital unit referred to in such paragraph. 

6 ‘‘(3) APPLICATION OF RATIOS TO HOSPITAL

7 NURSING PRACTICE STANDARDS.— 

8 ‘‘(A) IN GENERAL.—A patient assignment 

9 may be included in the calculation of the direct 

10 care registered nurse-to-patient ratios required 

11 in this subsection only if care is provided by a 

12 direct care registered nurse and the provision of 

13 care to the particular patient is within that di14 rect care registered nurse’s competence. 

15 ‘‘(B) DEMONSTRATION OF UNIT-SPECIFIC

16 COMPETENCE.—A hospital shall not assign a di17 rect care registered nurse to a hospital unit un18 less that hospital determines that the direct 

19 care registered nurse has demonstrated current 

20 competence in providing care in that unit, and 

21 has also received orientation to that hospital’s 

22 unit sufficient to provide competent care to pa23 tients in that unit. 

24 ‘‘(C) DUTIES OF THE ASSIGNED DIRECT

25 CARE REGISTERED NURSE.—Each patient shall 


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1 be assigned to a direct care registered nurse 

2 who shall directly provide the assessment, plan3 ning, supervision, implementation, and evalua4 tion of the nursing care provided to the patient 

5 at least every shift and has the responsibility 

6 for the provision of care to a particular patient 

7 within his or her scope of practice. 

8 ‘‘(D) NURSE ADMINISTRATORS AND SU9 PERVISORS.—A registered nurse who is a nurse 

10 administrator, nurse supervisor, nurse manager, 

11 charge nurse, case manager, or any other hos12 pital administrator or supervisor, shall not be 

13 included in the calculation of the direct care 

14 registered nurse-to-patient ratio unless that 

15 nurse has a current and active direct patient 

16 care assignment and provides direct patient 

17 care in compliance with the requirements of this 

18 section, including competency requirements. 

19 The exemption in this subsection shall apply 

20 only during the hours in which the individual 

21 registered nurse has the principal responsibility 

22 of providing direct patient care and has no ad23 ditional job duties as would a direct care reg24 istered nurse. 


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1 ‘‘(E) OTHER PERSONNEL.—Other per2 sonnel may perform patient care tasks based on 

3 their training and demonstrated skill but may 

4 not perform or assist in direct care registered 

5 nurse functions unless authorized to do in ac6 cordance with State scope of practice laws and 

7 regulations. 

8 ‘‘(F) TEMPORARY NURSING PERSONNEL.— 

9 A hospital shall not assign any nursing per10 sonnel from temporary nursing agencies patient 

11 care to any hospital unit without such personnel 

12 having demonstrated competence on the as13 signed unit and received orientation to that hos14 pital’s unit sufficient to provide competent care 

15 to patients in that unit. 

16 ‘‘(G) ANCILLARY AND ADDITIONAL STAFF17 ING.—The need for additional staffing of direct 

18 care registered nurses, licensed vocational or 

19 practical nurses, licensed psychiatric techni20 cians, certified nursing or patient care assist21 ants, or other licensed or unlicensed ancillary 

22 staff above the minimum registered nurse-to-pa23 tient ratios shall be based on the assessment of 

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1 ment, the individual patient’s nursing care plan, 

2 and acuity level. 

3 ‘‘(4) RESTRICTIONS.— 

4 ‘‘(A) PROHIBITION AGAINST AVERAGING.— 

5 A hospital shall not average the number of pa6 tients and the total number of direct care reg7 istered nurses assigned to patients in a hospital 

8 unit during any 1 shift or over any period of 

9 time for purposes of meeting the requirements 

10 under this subsection. 

11 ‘‘(B) PROHIBITION AGAINST IMPOSITION

12 OF MANDATORY OVERTIME REQUIREMENTS.—A 

13 hospital shall not impose mandatory overtime 

14 requirements to meet the hospital unit direct 

15 care registered nurse-to-patient ratios required 

16 under this subsection. 

17 ‘‘(C) RELIEF DURING ROUTINE AB18 SENCES.—A hospital shall ensure that only a 

19 direct care registered nurse who has dem20 onstrated current competence to the hospital in 

21 providing care on a particular unit and has also 

22 received orientation to that hospital’s unit suffi23 cient to provide competent care to patients in 

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1 istered nurse during breaks, meals, and other 

2 routine, expected absences from a hospital unit. 

3 ‘‘(D) APPLICATION OF DIRECT CARE REG4 ISTERED NURSE-TO-PATIENT RATIOS IN PA5 TIENT-ACUITY ADJUSTABLE UNITS.—Patients 

6 shall be cared for only on units or patient care 

7 areas where the direct care registered nurse-to8 patient ratios meet the level of intensity, type 

9 of care, and the individual requirements and 

10 needs of each patient. Notwithstanding para11 graph (2), hospitals that provide patient care in 

12 units or patient care areas that are acuity 

13 adaptable or acuity adjustable shall apply the 

14 direct care registered nurse-to-patient ratio re15 quired in this section for the highest patient 

16 acuity level or level of care in that unit or pa17 tient care area, and shall comply with all other 

18 requirements of this section. 

19 ‘‘(E) USE OF VIDEO MONITORS.—A hos20 pital shall not employ video monitors or any 

21 form of electronic visualization of a patient as 

22 a substitute for the direct observation required 

23 for patient assessment by the direct care reg24 istered nurse or required for patient protection. 

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1 ization of a patient shall not be included in the 

2 calculation of the direct care registered nurse3 to-patient ratio required in this subsection and 

4 shall not replace the requirement of paragraph 

5 (3)(D) that each patient shall be assigned to a 

6 direct care registered nurse who shall directly 

7 provide the assessment, planning, supervision, 

8 implementation, and evaluation of the nursing 

9 care provided to the patient at least every shift 

10 and have the responsibility for the provision of 

11 care to a particular patient within his or her 

12 scope of practice. 

13 ‘‘(F) USE OF OTHER TECHNOLOGY.—A 

14 hospital shall not employ technology that sub15 stitutes for the assigned registered nurse’s pro16 fessional judgment in assessment, planning, im17 plementation, and evaluation of care. 

18 ‘‘(5) ADJUSTMENT OF RATIOS.— 

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

20 patient safety, the Secretary may prescribe reg21 ulations that— 

22 ‘‘(i) increase minimum direct care reg23 istered nurse-to-patient ratios under this 

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1 tients that may be assigned to each direct 

2 care nurse; or 

3 ‘‘(ii) add minimum direct care reg4 istered nurse-to-patient ratios for units not 

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

6 ‘‘(B) CONSULTATION.—Such regulations 

7 shall be prescribed after consultation with af8 fected hospitals and registered nurses. 

9 ‘‘(6) ANCILLARY AND ADDITIONAL STAFFING.— 

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

11 prescribe regulations requiring additional staff12 ing of direct care registered nurses, licensed vo13 cational or practice nurses, licensed psychiatric 

14 technicians, certified nursing or patient care as15 sistants, or other licensed or unlicensed ancil16 lary staff above the minimum registered nurse17 to-patient ratios that is based on the assess18 ment of the individual patient’s nursing care 

19 needs, the individual patient’s nursing care 

20 plan, and acuity level. 

21 ‘‘(B) CONSULTATION.—Such regulations 

22 shall be prescribed after consultation with af23 fected hospitals, registered nurses, and ancillary 

24 staff. 


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1 ‘‘(7) RELATIONSHIP TO STATE-IMPOSED RA2 TIOS.—Nothing in this title shall preempt State 

3 standards that the Secretary determines to be as 

4 stringent as Federal requirements for a staffing plan 

5 established under this title. Minimum direct care 

6 registered nurse-to-patient ratios established under 

7 this subsection shall not preempt State requirements 

8 that the Secretary determines are as stringent as to 

9 Federal requirements for direct care registered 

10 nurse-to-patient ratios established under this title. 

11 ‘‘(8) EXEMPTION IN EMERGENCIES.—The re12 quirements established under this subsection shall 

13 not apply during a state of emergency if a hospital 

14 is requested or expected to provide an exceptional 

15 level of emergency or other medical services. If a 

16 hospital seeks to apply the exemption under this 

17 paragraph in response to a complaint filed against 

18 the hospital for a violation of the provisions of this 

19 title, the hospital must demonstrate that prompt and 

20 diligent efforts were made to maintain required 

21 staffing levels. The Secretary shall issue guidance to 

22 hospitals that describes situations that constitute a 

23 state of emergency for purposes of the exemption 

24 under this paragraph and shall establish necessary 


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1 penalties for violations of this paragraph consistent 

2 with section 3406. 

3 ‘‘(c) DEVELOPMENT AND REEVALUATION OF STAFF4 ING PLAN.— 

5 ‘‘(1) CONSIDERATIONS IN DEVELOPMENT OF

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

7 shall provide for direct care registered nurse-to-pa8 tient ratios above the minimum direct care reg9 istered nurse-to-patient ratios required under sub10 section (b) if appropriate based upon consideration 

11 of, at minimum, the following factors: 

12 ‘‘(A) The number of patients on a par13 ticular unit on a shift-by-shift basis. 

14 ‘‘(B) The acuity level and nursing care 

15 plan of patients on a particular unit on a shift16 by-shift basis. 

17 ‘‘(C) The anticipated admissions, dis18 charges, and transfers of patients during each 

19 shift that impacts direct patient care. 

20 ‘‘(D) Specialized experience required of di21 rect care registered nurses on a particular unit. 

22 ‘‘(E) Staffing levels and services provided 

23 by licensed vocational or practical nurses, li24 censed psychiatric technicians, certified nurse 

25 assistants, or other ancillary staff in meeting 


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1 direct patient care needs not required by a di2 rect care registered nurse. 

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

4 practices, policies, and procedures by temporary 

5 agency direct care registered nurses used dur6 ing a shift. 

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

8 of patient care presented by physical layout. 

9 ‘‘(2) DOCUMENTATION OF STAFFING.—A hos10 pital shall specify the system used to document ac11 tual staffing in each unit for each shift. 

12 ‘‘(3) ANNUAL REEVALUATION OF PLAN.— 

13 ‘‘(A) IN GENERAL.—A hospital shall annu14 ally evaluate its staffing plan in each unit in re15 lation to actual patient care requirements. 

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

17 staffing plan to the extent appropriate based on 

18 such evaluation. 

19 ‘‘(4) TRANSPARENCY.— 

20 ‘‘(A) IN GENERAL.—Any staffing plan or 

21 method used to create and evaluate acuity-level 

22 and adopted by a hospital under this section 

23 shall be transparent in all respects, including 

24 disclosure of detailed documentation of the 

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1 ing, identifying each factor, assumption, and 

2 value used in applying such methodology. 

3 ‘‘(B) PUBLIC AVAILABILITY.—The Sec4 retary shall establish procedures to provide that 

5 the documentation submitted under subsection 

6 (d) is available for public inspection in its en7 tirety. 

8 ‘‘(5) REGISTERED NURSE PARTICIPATION.—A 

9 staffing plan of a hospital— 

10 ‘‘(A) shall be developed and subsequent re11 evaluations shall be conducted under this sub12 section on the basis of input from direct care 

13 registered nurses at the hospital from each unit 

14 or patient care area; and 

15 ‘‘(B) where such nurses are represented 

16 through collective bargaining, shall require bar17 gaining with the applicable recognized or cer18 tified collective bargaining representative of 

19 such nurses. 

20 Nothing in this title shall be construed to permit 

21 conduct prohibited under the National Labor Rela22 tions Act (29 U.S.C. 151 et seq.) or chapter 71 of 

23 title 5, United States Code. 

24 ‘‘(6) STAFFING COMMITTEES.—If a hospital 

25 maintains a staffing committee, then the committee 


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1 shall include at least one registered nurse from each 

2 hospital unit and shall be composed of at least 50 

3 percent direct care registered nurses. The staffing 

4 committee shall include meaningful representation of 

5 other direct care nonmanagement staff. Direct care 

6 registered nurses who serve on the committee shall 

7 be selected by other direct care registered nurses 

8 from their unit. Other direct care nonmanagement 

9 staff shall be selected by other direct care non10 management staff. Participation on staffing commit11 tees shall be considered a part of the employee’s reg12 ularly scheduled workweek. 

13 ‘‘(d) SUBMISSION OF PLAN TO SECRETARY.—A hos14 pital shall submit to the Secretary its staffing plan and 

15 any annual updates under subsection (c)(3)(B). A feder16 ally operated hospital may submit its staffing plan 

17 through the department or agency operating the hospital. 

18 ‘‘SEC. 3402. POSTING, RECORDS, AND AUDITS. 

19 ‘‘(a) POSTING REQUIREMENTS.—In each unit, a hos20 pital shall post a uniform notice in a form specified by 

21 the Secretary in regulation that— 

22 ‘‘(1) explains requirements imposed under sec23 tion 3401; 

24 ‘‘(2) includes actual direct care registered 

25 nurse-to-patient ratios during each shift; 


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1 ‘‘(3) includes the actual number and titles of di2 rect care registered nurses assigned during each 

3 shift; and 

4 ‘‘(4) is visible, conspicuous, and accessible to 

5 staff, patients, and the public. 

6 ‘‘(b) RECORDS.— 

7 ‘‘(1) MAINTENANCE OF RECORDS.—Each hos8 pital shall maintain accurate records of actual direct 

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

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

11 shall include— 

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

13 ‘‘(B) the identity and duty hours of— 

14 ‘‘(i) each direct care registered nurse 

15 assigned to each patient in each unit in 

16 each shift; and 

17 ‘‘(ii) ancillary staff who are under the 

18 coordination of the direct care registered 

19 nurse; 

20 ‘‘(C) certification that each nurse received 

21 rest and meal breaks and the identity and duty 

22 hours of each direct care registered nurse who 

23 provided such relief; and 

24 ‘‘(D) a copy of each notice posted under 

25 subsection (a). 


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1 ‘‘(2) AVAILABILITY OF RECORDS.—Each hos2 pital shall make its records maintained under para3 graph (1) available to— 

4 ‘‘(A) the Secretary; 

5 ‘‘(B) registered nurses and their collective 

6 bargaining representatives (if any); and 

7 ‘‘(C) the public under regulations estab8 lished by the Secretary, or in the case of a fed9 erally operated hospital, under section 552 of 

10 title 5, United States Code (commonly known 

11 as the Freedom of Information Act). 

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

13 audits to ensure— 

14 ‘‘(1) implementation of the staffing plan in ac15 cordance with this title; and 

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

17 section. 

18 ‘‘SEC. 3403. MINIMUM DIRECT CARE LICENSED PRACTICAL 

19 NURSE STAFFING REQUIREMENTS. 

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

21 shall comply with minimum direct care licensed practical 

22 nurse staffing requirements that the Secretary establishes 

23 for units in hospitals. Such staffing requirements shall be 

24 established not later than 18 months after the date of the 


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

2 conducted under subsection (b). 

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

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

5 through the Director of the Agency for Healthcare Re6 search and Quality, shall complete a study of licensed 

7 practical nurse staffing and its effects on patient care in 

8 hospitals. The Director may contract with a qualified enti9 ty or organization to carry out such study under this para10 graph. The Director shall consult with licensed practical 

11 nurses and organizations representing licensed practical 

12 nurses regarding the design and conduct of the study. 

13 ‘‘(c) APPLICATION OF REGISTERED NURSE PROVI14 SIONS TO LICENSED PRACTICAL NURSE STAFFING RE15 QUIREMENTS.—Paragraphs (2), (4)(A), (4)(B), (4)(C), 

16 and (6) of section 3401(b), paragraphs (1), (2), (3), and 

17 (4) of section 3401(c), and section 3402 shall apply to 

18 the establishment and application of direct care licensed 

19 practical nurse staffing requirements under this section 

20 pursuant to the additional staffing requirements under 

21 subsection (b)(3)(G) of section 3401 and in the same man22 ner that they apply to the establishment and application 

23 of direct care registered nurse-to-patient ratios under sec24 tions 3401 and 3402. 


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

2 section shall take effect as soon as practicable, as deter3 mined by the Secretary, but not later than— 

4 ‘‘(1) 2 years after the date of the enactment of 

5 this title; and 

6 ‘‘(2) in the case of a hospital in a rural area 

7 (as defined in section 1886(d)(2)(D) of the Social 

8 Security Act), 4 years after the date of the enact9 ment of this title. 

10 ‘‘(e) STUDY.—Not later than 1 year after the date 

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

12 through the Director of the Agency for Healthcare Re13 search and Quality shall complete a study of registered 

14 and practical nurse staffing requirements in clinics and 

15 other outpatient settings, and its effects on patient care 

16 in outpatient settings. The Director may contract with a 

17 qualified entity or organization to carry out such study 

18 under this subsection. The Director shall consult with reg19 istered nurses and licensed practice nurses working in out20 patient settings, including professional nursing associa21 tions and labor organizations representing both registered 

22 and practice nurses working in outpatient settings regard23 ing the design and conduct of the study. 


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1 ‘‘SEC. 3404. ADJUSTMENT IN REIMBURSEMENT. 

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

3 shall adjust payments made to hospitals (other than feder4 ally operated hospitals) under title XVIII of the Social Se5 curity Act in an amount equal to the net amount of addi6 tional costs incurred in providing services to Medicare 

7 beneficiaries that are attributable to compliance with re8 quirements imposed under sections 3401 through 3403. 

9 The amount of such payment adjustments shall take into 

10 account recommendations contained in the report sub11 mitted by the Medicare Payment Advisory Commission 

12 under subsection (c). 

13 ‘‘(b) AUTHORIZATION OF APPROPRIATION FOR FED14 ERALLY OPERATED HOSPITALS.—There are authorized to 

15 be appropriated such additional sums as are required for 

16 federally operated hospitals to comply with the additional 

17 requirements established under sections 3401 through 

18 3403. 

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

20 after the date of the enactment of this title, the Medicare 

21 Payment Advisory Commission (established under section 

22 1805 of the Social Security Act) shall submit to Congress 

23 and the Secretary a report estimating total costs and sav24 ings attributable to compliance with requirements imposed 

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1 clude recommendations on the need, if any, to adjust reim2 bursement for Medicare payments under subsection (a). 

3 ‘‘SEC. 3405. WHISTLEBLOWER AND PATIENT PROTECTIONS. 

4 ‘‘(a) PROFESSIONAL OBLIGATION AND RIGHTS.—All 

5 nurses have a duty and right to act based on their profes6 sional judgment in accordance with State nursing laws 

7 and regulations of the State in which the direct nursing 

8 care is being performed and to provide care in the exclu9 sive interests of the patients and to act as the patient’s 

10 advocate. 

11 ‘‘(b) ACCEPTANCE OF PATIENT CARE ASSIGN12 MENTS.—The nurse is responsible for providing com13 petent, safe, therapeutic, and effective nursing care to as14 signed patients. Before accepting a patient assignment, a 

15 nurse shall— 

16 ‘‘(1) have the necessary professional knowledge, 

17 judgment, skills, and ability to provide the required 

18 care; 

19 ‘‘(2) determine using professional judgment in 

20 accordance with State nursing laws and regulations 

21 of the State in which the direct nursing care is being 

22 performed whether the nurse is competent to per23 form the nursing care required; and 


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1 ‘‘(3) determine whether acceptance of a patient 

2 assignment would expose the patient or nurse to risk 

3 of harm. 

4 ‘‘(c) OBJECTION TO OR REFUSAL OF ASSIGNMENT.— 

5 A nurse may object to, or refuse to participate in, any 

6 activity, policy, practice, assignment, or task if in good 

7 faith— 

8 ‘‘(1) the nurse reasonably believes it to be in 

9 violation of section 3401 or 3403; or 

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

11 training, or experience to fulfill the assignment with12 out compromising the safety of any patient or jeop13 ardizing the license of the nurse. 

14 ‘‘(d) RETALIATION FOR OBJECTION TO OR REFUSAL

15 OF ASSIGNMENT BARRED.— 

16 ‘‘(1) NO DISCHARGE, DISCRIMINATION, OR RE17 TALIATION.—No hospital shall discharge, retaliate, 

18 discriminate, or otherwise take adverse action in any 

19 manner with respect to any aspect of a nurse’s em20 ployment (as defined in section 3407), including dis21 charge, promotion, compensation, or terms, condi22 tions, or privileges of employment, based on the 

23 nurse’s refusal of a work assignment under sub24 section (c). 


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

2 shall file a complaint or a report against a nurse 

3 with a State professional disciplinary agency because 

4 of the nurse’s refusal of a work assignment under 

5 subsection (c). 

6 ‘‘(e) CAUSE OF ACTION.—Any nurse, collective bar7 gaining representative, or legal representative of any nurse 

8 who has been discharged, discriminated against, or retali9 ated against in violation of subsection (d)(1) or against 

10 whom a complaint or report has been filed in violation of 

11 subsection (d)(2) may (without regard to whether a com12 plaint has been filed under subsection (f) of this section 

13 or subsection (b) of section 3406) bring a cause of action 

14 in a United States district court. A nurse who prevails 

15 on the cause of action shall be entitled to one or more 

16 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 ‘‘(f) COMPLAINT TO SECRETARY.—A nurse, patient, 

24 collective bargaining representative, or other individual 

25 may file a complaint with the Secretary against a hospital 


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1 that violates the provisions of this title. For any complaint 

2 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 discharge, retaliation, discrimination, 

9 or other adverse action prohibited by subsection (d) 

10 or subsection (h). 

11 ‘‘(g) TOLL-FREE TELEPHONE NUMBER.— 

12 ‘‘(1) IN GENERAL.—The Secretary shall provide 

13 for the establishment of a toll-free telephone hotline 

14 to provide information regarding the requirements 

15 under section 3401 through 3403 and to receive re16 ports of violations of such section. 

17 ‘‘(2) NOTICE TO PATIENTS.—A hospital shall 

18 provide each patient admitted to the hospital for in19 patient care with the hotline described in paragraph 

20 (1), and shall give notice to each patient that such 

21 hotline may be used to report inadequate staffing or 

22 care. 

23 ‘‘(h) PROTECTION FOR REPORTING.— 

24 ‘‘(1) PROHIBITION ON RETALIATION OR DIS25 CRIMINATION.—A hospital shall not discriminate or 


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1 retaliate in any manner against any patient, em2 ployee, or contract employee of the hospital, or any 

3 other individual, on the basis that such individual, in 

4 good faith, individually or in conjunction with an5 other person or persons, has presented a grievance 

6 or complaint, or has initiated or cooperated in any 

7 investigation or proceeding of any governmental en8 tity, regulatory agency, or private accreditation 

9 body, made a civil claim or demand, or filed an ac10 tion relating to the care, services, or conditions of 

11 the hospital or of any affiliated or related facilities. 

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

13 this subsection, an individual shall be deemed to be 

14 acting in good faith if the individual reasonably be15 lieves— 

16 ‘‘(A) the information reported or disclosed 

17 is true; and 

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

19 or may occur. 

20 ‘‘(i) PROHIBITION ON INTERFERENCE WITH

21 RIGHTS.— 

22 ‘‘(1) EXERCISE OF RIGHTS.—It shall be unlaw23 ful for any hospital to— 

24 ‘‘(A) interfere with, restrain, or deny the 

25 exercise, or attempt to exercise, by any person 


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1 of any right provided or protected under this 

2 title; or 

3 ‘‘(B) coerce or intimidate any person re4 garding the exercise or attempt to exercise such 

5 right. 

6 ‘‘(2) OPPOSITION TO UNLAWFUL POLICIES OR

7 PRACTICES.—It shall be unlawful for any hospital to 

8 discriminate or retaliate against any person for op9 posing any hospital policy, practice, or actions which 

10 are alleged to violate, breach, or fail to comply with 

11 any provision of this title. 

12 ‘‘(3) PROHIBITION ON INTERFERENCE WITH

13 PROTECTED COMMUNICATIONS.—A hospital (or an 

14 individual representing a hospital) shall not make, 

15 adopt, or enforce any rule, regulation, policy, or 

16 practice which in any manner directly or indirectly 

17 prohibits, impedes, or discourages a direct care 

18 nurse from, or intimidates, coerces, or induces a di19 rect care nurse regarding, engaging in free speech 

20 activities or disclosing information as provided under 

21 this title. 

22 ‘‘(4) PROHIBITION ON INTERFERENCE WITH

23 COLLECTIVE ACTION.—A hospital (or an individual 

24 representing a hospital) shall not in any way inter25 fere with the rights of nurses to organize, bargain 


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1 collectively, and engage in concerted activity under 

2 section 7 of the National Labor Relations Act (29 

3 U.S.C. 157). 

4 ‘‘(j) NOTICE.—A hospital shall post in an appropriate 

5 location in each unit a conspicuous notice in a form speci6 fied by the Secretary that— 

7 ‘‘(1) explains the rights of nurses, patients, and 

8 other individuals under this section; 

9 ‘‘(2) includes a statement that a nurse, patient, 

10 or other individual may file a complaint with the 

11 Secretary against a hospital that violates the provi12 sions of this title; and 

13 ‘‘(3) provides instructions on how to file such a 

14 complaint. 

15 ‘‘(k) EFFECTIVE DATE.— 

16 ‘‘(1) REFUSAL; RETALIATION; CAUSE OF AC17 TION.— 

18 ‘‘(A) IN GENERAL.—Subsections (c) 

19 through (e) shall apply to objections and refus20 als occurring on or after the effective date of 

21 the provision of this title to which the objection 

22 or refusal relates. 

23 ‘‘(B) EXCEPTION.—Subsection (c)(2) shall 

24 not apply to objections or refusals in any hos25 pital before the requirements of section 3401(a) 


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1 or 3403(a), as applicable, apply to that hos2 pital. 

3 ‘‘(2) PROTECTIONS FOR REPORTING.—Sub4 section (h)(1) shall apply to actions occurring on or 

5 after the effective date of the provision to which the 

6 violation relates, except that such subsection shall 

7 apply to initiation, cooperation, or participation in 

8 an investigation or proceeding on or after the date 

9 of enactment of this title. 

10 ‘‘(3) NOTICE.—Subsection (j) shall take effect 

11 18 months after the date of enactment of this title. 

12 ‘‘SEC. 3406. ENFORCEMENT. 

13 ‘‘(a) IN GENERAL.—The Secretary shall enforce the 

14 requirements and prohibitions of this title in accordance 

15 with this section. 

16 ‘‘(b) PROCEDURES FOR RECEIVING AND INVES17 TIGATING COMPLAINTS.—The Secretary shall establish 

18 procedures under which— 

19 ‘‘(1) any person may file a complaint alleging 

20 that a hospital has violated a requirement or a pro21 hibition of this title; and 

22 ‘‘(2) such complaints shall be investigated by 

23 the Secretary. 


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1 ‘‘(c) REMEDIES.—If the Secretary determines that a 

2 hospital has violated a requirement of this title, the Sec3 retary— 

4 ‘‘(1) shall require the facility to establish a cor5 rective action plan to prevent the recurrence of such 

6 violation; and 

7 ‘‘(2) may impose civil money penalties, as de8 scribed in subsection (d). 

9 ‘‘(d) CIVIL PENALTIES.— 

10 ‘‘(1) IN GENERAL.—In addition to any other 

11 penalties prescribed by law, the Secretary may im12 pose civil penalties as follows: 

13 ‘‘(A) HOSPITAL LIABILITY.—The Secretary 

14 may impose on a hospital found to be in viola15 tion of this title a civil money penalty of— 

16 ‘‘(i) not more than $25,000 for the 

17 first knowing violation of this title by such 

18 hospital; and 

19 ‘‘(ii) not more than $50,000 for any 

20 subsequent knowing violation of this title 

21 by such hospital. 

22 ‘‘(B) INDIVIDUAL LIABILITY.—The Sec23 retary may impose on an individual who— 


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1 ‘‘(i) is employed by a hospital found 

2 by the Secretary to have violated this title; 

3 and 

4 ‘‘(ii) knowingly violates this title, 

5 a civil money penalty of not more than $20,000 

6 for each such violation by the individual. 

7 ‘‘(2) PROCEDURES.—The provisions of section 

8 1128A of the Social Security Act (other than sub9 sections (a) and (b)) shall apply with respect to a 

10 civil money penalty or proceeding under this sub11 section in the same manner as such provisions apply 

12 with respect to a civil money penalty or proceeding 

13 under such section 1128A. 

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

15 ‘‘(1) INTERNET WEBSITE.—The Secretary shall 

16 publish on the internet website of the Department of 

17 Health and Human Services the names of hospitals 

18 on which a civil money penalty has been imposed 

19 under this section, the violation for which such pen20 alty was imposed, and such additional information 

21 as the Secretary determines appropriate. 

22 ‘‘(2) CHANGE OF OWNERSHIP.—With respect to 

23 a hospital that had a change of ownership, as deter24 mined by the Secretary, penalties imposed on the 

25 hospital while under previous ownership shall no 


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1 longer be published by the Secretary pursuant to 

2 paragraph (1) after the 1-year period beginning on 

3 the date of change of ownership. 

4 ‘‘(f) USE OF FUNDS.—Funds collected by the Sec5 retary pursuant to this section are authorized to be appro6 priated to carry out this title. 

7 ‘‘SEC. 3407. DEFINITIONS. 

8 ‘‘For purposes of this title: 

9 ‘‘(1) ACUITY LEVEL.—The term ‘acuity level’ 

10 means the determination, using a hospital acuity 

11 measurement tool that has been developed and es12 tablished in coordination with direct care registered 

13 nurses and made transparent pursuant to section 

14 3401(c)(4), of nursing care requirements, based on 

15 the assigned direct care registered nurse’s profes16 sional judgment of— 

17 ‘‘(A) the severity and complexity of an in18 dividual patient’s illness or injury; 

19 ‘‘(B) the need for specialized equipment; 

20 and 

21 ‘‘(C) the intensity of nursing interventions 

22 required. 

23 ‘‘(2) COMPETENCE.—The term ‘competence’ or 

24 ‘competent’ means the satisfactory application of the 

25 duties and responsibilities of a registered nurse in 


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1 providing nursing care to specific patient popu2 lations and for acuity levels for each patient care 

3 unit or area pursuant to the State nursing laws and 

4 regulations of the State in which the direct nursing 

5 care is being performed. 

6 ‘‘(3) DIRECT CARE LICENSED PRACTICAL

7 NURSE.—The term ‘direct care licensed practical 

8 nurse’ means an individual who has been granted a 

9 license by at least one State to practice as a licensed 

10 practical nurse or a licensed vocational nurse and 

11 who provides bedside care for one or more patients. 

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

13 term ‘direct care registered nurse’ means an indi14 vidual who has been granted a license by at least 

15 one State to practice as a registered nurse and who 

16 provides bedside care for one or more patients. 

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

18 includes the provision of services under a contract or 

19 other arrangement. 

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

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

22 Social Security Act, and includes a hospital that is 

23 operated by the Department of Veterans Affairs, the 

24 Department of Defense, the Indian Health Services 


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1 Program, or any other department or agency of the 

2 United States. 

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

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

6 whether or not the nurse is an employee. 

7 ‘‘(8) NURSING CARE PLAN.—The term ‘nursing 

8 care plan’ means a plan developed by the assigned 

9 direct care registered nurse (in accordance with 

10 nursing law in the State in which the nursing care 

11 is performed) that indicates the nursing care to be 

12 given to individual patients that— 

13 ‘‘(A) considers the acuity level of the pa14 tient; 

15 ‘‘(B) is developed in coordination with the 

16 patient, the patient’s family, or other represent17 atives when appropriate, and staff of other dis18 ciplines involved in the care of the patient; 

19 ‘‘(C) reflects all elements of the nursing 

20 process; and 

21 ‘‘(D) recommends the number and skill 

22 mix of additional licensed and unlicensed direct 

23 care staff needed to fully implement the nursing 

24 care plan. 


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1 ‘‘(9) PROFESSIONAL JUDGMENT.—The term 

2 ‘professional judgment’ means, in accordance with 

3 State nursing laws and regulations of the State in 

4 which the direct nursing care is being performed, the 

5 direct care registered nurse’s application of knowl6 edge, expertise, and experience in conducting a com7 prehensive nursing assessment of each patient and 

8 in making independent decisions about patient care 

9 including the need for additional staff. 

10 ‘‘(10) STAFFING PLAN.—The term ‘staffing 

11 plan’ means a staffing plan required under section 

12 3401. 

13 ‘‘(11) STATE OF EMERGENCY.—The term ‘state 

14 of emergency’— 

15 ‘‘(A) means a state of emergency that is 

16 an unpredictable or unavoidable occurrence at 

17 an unscheduled or unpredictable interval, relat18 ing to health care delivery and requiring imme19 diate medical interventions and care; and 

20 ‘‘(B) does not include a state of emergency 

21 that results from a labor dispute in the health 

22 care industry or consistent understaffing. 

23 ‘‘SEC. 3408. RULE OF CONSTRUCTION. 

24 ‘‘Nothing in this title shall be construed to authorize 

25 disclosure of private and confidential patient information, 


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1 if such disclosure is not authorized or required by other 

2 applicable law.’’. 

3 (b) RECOMMENDATIONS TO CONGRESS.—Not later 

4 than 1 year after the date of enactment of this Act, the 

5 Secretary of Health and Human Services shall submit to 

6 Congress a report containing recommendations for ensur7 ing that sufficient numbers of nurses are available to meet 

8 the requirements imposed by title XXXIV of the Public 

9 Health Service Act, as added by subsection (a). 

10 (c) REPORT BY HRSA.— 

11 (1) IN GENERAL.—Not later than 2 years after 

12 the date of enactment of this Act, the Administrator 

13 of the Health Resources and Services Administra14 tion, in consultation with the National Health Care 

15 Workforce Commission, shall submit to Congress a 

16 report regarding the relationship between nurse 

17 staffing levels and nurse retention in hospitals. 

18 (2) UPDATED REPORT.—Not later than 5 years 

19 after the date of enactment of this Act, the Adminis20 trator of the Health Resources and Services Admin21 istration, in consultation with the National Health 

22 Care Workforce Commission, shall submit to Con23 gress an update of the report submitted under para24 graph (1). 


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1 SEC. 3. ENFORCEMENT OF REQUIREMENTS THROUGH FED2 ERAL PROGRAMS. 

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

4 Social Security Act (42 U.S.C. 1395cc(a)(1)) is amend5 ed— 

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

7 and inserting a comma; 

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

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

10 (3) by inserting after the subparagraph (Y) the 

11 following new subparagraph: 

12 ‘‘(Z) in the case of a hospital, to comply with 

13 the provisions of title XXXIV of the Public Health 

14 Service Act.’’. 

15 (b) MEDICAID PROGRAM.—Section 1902(a) of the 

16 Social Security Act (42 U.S.C. 1396a(a)) is amended— 

17 (1) by striking ‘‘and’’ at the end of paragraph 

18 (86); 

19 (2) by striking the period at the end of para20 graph (87)(D) and inserting ‘‘; and’’; and 

21 (3) by inserting after paragraph (87) the fol22 lowing new paragraph: 

23 ‘‘(88) provide that any hospital that receives a 

24 payment under such plan comply with the provisions 

25 of title XXXIV of the Public Health Service Act (reVerDate Sep 11 2014 03:20 Jun 12, 2021 Jkt 019200 PO 00000 Frm 00039 Fmt 6652 Sfmt 6201 E:\BILLS\H3165.IH H3165

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1 lating to minimum direct care registered nurse staff2 ing requirements).’’. 

3 (c) HEALTH BENEFITS PROGRAM OF THE DEPART4 MENT OF VETERANS AFFAIRS.—Section 8110(a) of title 

5 38, United States Code, is amended by adding at the end 

6 the following new paragraphs: 

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

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

9 of title XXXIV of the Public Health Service Act. 

10 ‘‘(8) Nothing either in chapter 74 of this title or in 

11 section 7106 of title 5 shall preclude enforcement of the 

12 provisions of title XXXIV of the Public Health Service Act 

13 with respect to a Department hospital through grievance 

14 procedures negotiated in accordance with chapter 71 of 

15 title 5.’’. 

16 (d) HEALTH BENEFITS PROGRAM OF THE DEPART17 MENT OF DEFENSE.— 

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

19 United States Code, is amended by adding at the 

20 end the following new section: 

21 ‘‘§ 1110c. Staffing requirements 

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

23 that is a hospital, the hospital shall comply with the provi24 sions of title XXXIV of the Public Health Service Act.’’. 


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1 (2) CLERICAL AMENDMENT.—The table of sec2 tions at the beginning of such chapter is amended 

3 by inserting after the item relating to section 1110b 

4 the following new item: 

‘‘1110c. Staffing requirements.’’. 

5 (e) INDIAN HEALTH SERVICES PROGRAM.—Title 

6 VIII of the Indian Health Care Improvement Act (25 

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

8 the following new section: 

9 ‘‘SEC. 833. STAFFING REQUIREMENTS. 

10 ‘‘All hospitals of the Service shall comply with the 

11 provisions of title XXXIV of the Public Health Service Act 

12 (relating to minimum direct care registered nurse staffing 

13 requirements).’’. 

14 (f) FEDERAL LABOR-MANAGEMENT RELATIONS.— 

15 (1) IN GENERAL.—Section 7106 of title 5, 

16 United States Code, is amended by adding at the 

17 end the following: 

18 ‘‘(c) Nothing in this section shall preclude enforce19 ment of the provisions of title XXXIV of the Public Health 

20 Service Act through grievance procedures negotiated in ac21 cordance with section 7121.’’. 

22 (2) CONFORMING AMENDMENT.—Section 

23 7106(a) of title 5, United States Code, is amended 

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1 tion,’’ and inserting ‘‘Subject to subsections (b) and 

2 (c),’’. 

3 SEC. 4. NURSE WORKFORCE INITIATIVE. 

4 (a) SCHOLARSHIP AND STIPEND PROGRAM.—Sub5 section (d) of section 846 of the Public Health Service 

6 Act (42 U.S.C. 297n) is amended— 

7 (1) in the subsection heading, by inserting 

8 ‘‘AND STIPEND’’ after ‘‘SCHOLARSHIP’’; and 

9 (2) in paragraph (1), by inserting ‘‘or stipends’’ 

10 after ‘‘scholarships’’. 

11 (b) NURSE RETENTION GRANTS.—Section 831(c)(1) 

12 of the Public Health Service Act (42 U.S.C. 296p(c)(1)) 

13 is amended— 

14 (1) by striking ‘‘GRANTS FOR CAREER LADDER

15 PROGRAMS’’ and inserting ‘‘GRANTS FOR NURSE RE16 TENTION’’; 

17 (2) in subparagraph (B), by striking ‘‘; and’’ 

18 and inserting a semicolon; 

19 (3) in subparagraph (C), by striking the period 

20 at the end and inserting a semicolon; and 

21 (4) by adding at the end the following: 

22 ‘‘(D) to provide additional support to 

23 nurses entering the workforce by implementing 

24 nursing preceptorship projects that establish a 

25 period of practical and clinical experiences and 


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1 training for nursing students, newly hired 

2 nurses, and recent graduates of a direct care 

3 degree program for registered nurses; and 

4 ‘‘(E) to implement mentorship projects 

5 that assist new or transitional direct care reg6 istered nurses in adapting to the hospital set7 ting.’’. 

Æ 


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