Act (42 U.S.C. 201 et seq.) is amended by adding at the 
end the following new title: 
‘‘TITLE 
XXXIV—MINIMUM 
DI-
RECT 
CARE 
REGISTERED 
NURSE STAFFING REQUIRE-
MENT 
‘‘SEC. 3401. MINIMUM NURSE STAFFING REQUIREMENT. 
‘‘(a) STAFFING PLAN.— 
‘‘(1) IN GENERAL.—A hospital shall implement 
a staffing plan that— 
‘‘(A) provides adequate, appropriate, and 
quality delivery of health care services and pro-
tects patient safety; and 
‘‘(B) is consistent with the requirements of 
this title. 
‘‘(2) EFFECTIVE DATES.— 
‘‘(A) 
IMPLEMENTATION
OF
STAFFING 
PLAN.—Subject to subparagraph (B), the re-
quirements under paragraph (1) shall take ef-
fect on a date to be determined by the Sec-
retary, but not later than 1 year after the date 
of the enactment of this title. 
‘‘(B) APPLICATION
OF
MINIMUM
DIRECT 
CARE
REGISTERED
NURSE-TO-PATIENT
RA-
TIOS.—The requirements under subsection (b) 
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shall take effect as soon as practicable, as de-
termined by the Secretary, but not later than— 
‘‘(i) 2 years after the date of enact-
ment of this title; and 
‘‘(ii) in the case of a hospital in a 
rural 
area 
(as 
defined 
in 
section 
1886(d)(2)(D) of the Social Security Act), 
4 years after the date of enactment of this 
title. 
‘‘(b) MINIMUM DIRECT CARE REGISTERED NURSE- 
TO-PATIENT RATIOS.— 
‘‘(1) IN GENERAL.—Except as provided in para-
graph (4) and other provisions of this section, a hos-
pital’s staffing plan shall provide that, at all times 
during each shift within a unit of the hospital, and 
with a full complement of ancillary and support 
staff, a direct care registered nurse may be assigned 
to not more than the following number of patients 
in that unit: 
‘‘(A) One patient in trauma emergency 
units. 
‘‘(B) One patient in operating room units, 
provided that a minimum of 1 additional person 
serves as a scrub assistant in such unit. 
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‘‘(C) Two patients in critical care units, in-
cluding neonatal intensive care units, emer-
gency critical care and intensive care units, 
labor and delivery units, coronary care units, 
acute respiratory care units, postanesthesia 
units, and burn units. 
‘‘(D) Three patients in emergency room 
units, pediatrics units, stepdown units, telem-
etry units, antepartum units, and combined 
labor, deliver, and postpartum units. 
‘‘(E) Four patients in medical-surgical 
units, intermediate care nursery units, acute 
care psychiatric units, and other specialty care 
units. 
‘‘(F) Five patients in rehabilitation units 
and skilled nursing units. 
‘‘(G) Six patients in postpartum (3 cou-
plets) units and well-baby nursery units. 
‘‘(2) 
SIMILAR
UNITS
WITH
DIFFERENT 
NAMES.—The Secretary may apply minimum direct 
care registered nurse-to-patient ratios established in 
paragraph (1) for a hospital unit referred to in such 
paragraph to a type of hospital unit not referred to 
in such paragraph if such type of hospital unit pro-
vides a level of care to patients whose needs are 
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similar to the needs of patients cared for in the hos-
pital unit referred to in such paragraph. 
‘‘(3) APPLICATION
OF
RATIOS
TO
HOSPITAL 
NURSING PRACTICE STANDARDS.— 
‘‘(A) IN GENERAL.—A patient assignment 
may be included in the calculation of the direct 
care registered nurse-to-patient ratios required 
in this subsection only if care is provided by a 
direct care registered nurse and the provision of 
care to the particular patient is within that di-
rect care registered nurse’s competence. 
‘‘(B) DEMONSTRATION OF UNIT-SPECIFIC 
COMPETENCE.—A hospital shall not assign a di-
rect care registered nurse to a hospital unit un-
less that hospital determines that the direct 
care registered nurse has demonstrated current 
competence in providing care in that unit, and 
has also received orientation to that hospital’s 
unit sufficient to provide competent care to pa-
tients in that unit. 
‘‘(C) DUTIES OF THE ASSIGNED DIRECT 
CARE REGISTERED NURSE.—Each patient shall 
be assigned to a direct care registered nurse 
who shall directly provide the assessment, plan-
ning, supervision, implementation, and evalua-
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tion of the nursing care provided to the patient 
at least every shift and has the responsibility 
for the provision of care to a particular patient 
within his or her scope of practice. 
‘‘(D) NURSE
ADMINISTRATORS
AND
SU-
PERVISORS.—A registered nurse who is a nurse 
administrator, nurse supervisor, nurse manager, 
charge nurse, case manager, or any other hos-
pital administrator or supervisor, shall not be 
included in the calculation of the direct care 
registered nurse-to-patient ratio unless that 
nurse has a current and active direct patient 
care assignment and provides direct patient 
care in compliance with the requirements of this 
section, including competency requirements. 
The exemption in this subsection shall apply 
only during the hours in which the individual 
registered nurse has the principal responsibility 
of providing direct patient care and has no ad-
ditional job duties as would a direct care reg-
istered nurse. 
‘‘(E) OTHER
PERSONNEL.—Other per-
sonnel may perform patient care tasks based on 
their training and demonstrated skill but may 
not perform or assist in direct care registered 
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nurse functions unless authorized to do in ac-
cordance with State scope of practice laws and 
regulations. 
‘‘(F) TEMPORARY NURSING PERSONNEL.— 
A hospital shall not assign any nursing per-
sonnel from temporary nursing agencies patient 
care to any hospital unit without such personnel 
having demonstrated competence on the as-
signed unit and received orientation to that hos-
pital’s unit sufficient to provide competent care 
to patients in that unit. 
‘‘(G) ANCILLARY AND ADDITIONAL STAFF-
ING.—The need for additional staffing of direct 
care registered nurses, licensed vocational or 
practical nurses, licensed psychiatric techni-
cians, certified nursing or patient care assist-
ants, or other licensed or unlicensed ancillary 
staff above the minimum registered nurse-to-pa-
tient ratios shall be based on the assessment of 
the individual patient’s nursing care require-
ment, the individual patient’s nursing care plan, 
and acuity level. 
‘‘(4) RESTRICTIONS.— 
‘‘(A) PROHIBITION AGAINST AVERAGING.— 
A hospital shall not average the number of pa-
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tients and the total number of direct care reg-
istered nurses assigned to patients in a hospital 
unit during any 1 shift or over any period of 
time for purposes of meeting the requirements 
under this subsection. 
‘‘(B) PROHIBITION
AGAINST
IMPOSITION 
OF MANDATORY OVERTIME REQUIREMENTS.—A 
hospital shall not impose mandatory overtime 
requirements to meet the hospital unit direct 
care registered nurse-to-patient ratios required 
under this subsection. 
‘‘(C) 
RELIEF
DURING
ROUTINE
AB-
SENCES.—A hospital shall ensure that only a 
direct care registered nurse who has dem-
onstrated current competence to the hospital in 
providing care on a particular unit and has also 
received orientation to that hospital’s unit suffi-
cient to provide competent care to patients in 
that unit may relieve another direct care reg-
istered nurse during breaks, meals, and other 
routine, expected absences from a hospital unit. 
‘‘(D) APPLICATION OF DIRECT CARE REG-
ISTERED
NURSE-TO-PATIENT
RATIOS
IN
PA-
TIENT-ACUITY
ADJUSTABLE
UNITS.—Patients 
shall be cared for only on units or patient care 
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areas where the direct care registered nurse-to- 
patient ratios meet the level of intensity, type 
of care, and the individual requirements and 
needs of each patient. Notwithstanding para-
graph (2), hospitals that provide patient care in 
units or patient care areas that are acuity 
adaptable or acuity adjustable shall apply the 
direct care registered nurse-to-patient ratio re-
quired in this section for the highest patient 
acuity level or level of care in that unit or pa-
tient care area, and shall comply with all other 
requirements of this section. 
‘‘(E) USE OF VIDEO MONITORS.—A hos-
pital shall not employ video monitors or any 
form of electronic visualization of a patient as 
a substitute for the direct observation required 
for patient assessment by the direct care reg-
istered nurse or required for patient protection. 
Video monitors or any form of electronic visual-
ization of a patient shall not be included in the 
calculation of the direct care registered nurse- 
to-patient ratio required in this subsection and 
shall not replace the requirement of paragraph 
(3)(D) that each patient shall be assigned to a 
direct care registered nurse who shall directly 
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provide the assessment, planning, supervision, 
implementation, and evaluation of the nursing 
care provided to the patient at least every shift 
and have the responsibility for the provision of 
care to a particular patient within his or her 
scope of practice. 
‘‘(F) USE
OF
OTHER
TECHNOLOGY.—A 
hospital shall not employ technology that sub-
stitutes for the assigned registered nurse’s pro-
fessional judgment in assessment, planning, im-
plementation, and evaluation of care. 
‘‘(5) ADJUSTMENT OF RATIOS.— 
‘‘(A) IN GENERAL.—If necessary to protect 
patient safety, the Secretary may prescribe reg-
ulations that— 
‘‘(i) increase minimum direct care reg-
istered nurse-to-patient ratios under this 
subsection to reduce the number of pa-
tients that may be assigned to each direct 
care nurse; or 
‘‘(ii) add minimum direct care reg-
istered nurse-to-patient ratios for units not 
referred to in paragraphs (1) and (2). 
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‘‘(B) CONSULTATION.—Such regulations 
shall be prescribed after consultation with af-
fected hospitals and registered nurses. 
‘‘(6) ANCILLARY AND ADDITIONAL STAFFING.— 
‘‘(A) IN
GENERAL.—The Secretary may 
prescribe regulations requiring additional staff-
ing of direct care registered nurses, licensed vo-
cational or practice nurses, licensed psychiatric 
technicians, certified nursing or patient care as-
sistants, or other licensed or unlicensed ancil-
lary staff above the minimum registered nurse- 
to-patient ratios that is based on the assess-
ment of the individual patient’s nursing care 
needs, the individual patient’s nursing care 
plan, and acuity level. 
‘‘(B) CONSULTATION.—Such regulations 
shall be prescribed after consultation with af-
fected hospitals, registered nurses, and ancillary 
staff. 
‘‘(7) RELATIONSHIP
TO
STATE-IMPOSED
RA-
TIOS.—Nothing in this title shall preempt State 
standards that the Secretary determines to be as 
stringent as Federal requirements for a staffing plan 
established under this title. Minimum direct care 
registered nurse-to-patient ratios established under 
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this subsection shall not preempt State requirements 
that the Secretary determines are as stringent as to 
Federal requirements for direct care registered 
nurse-to-patient ratios established under this title. 
‘‘(8) EXEMPTION IN EMERGENCIES.—The re-
quirements established under this subsection shall 
not apply during a state of emergency if a hospital 
is requested or expected to provide an exceptional 
level of emergency or other medical services. If a 
hospital seeks to apply the exemption under this 
paragraph in response to a complaint filed against 
the hospital for a violation of the provisions of this 
title, the hospital must demonstrate that prompt and 
diligent efforts were made to maintain required 
staffing levels. The Secretary shall issue guidance to 
hospitals that describes situations that constitute a 
state of emergency for purposes of the exemption 
under this paragraph and shall establish necessary 
penalties for violations of this paragraph consistent 
with section 3406. 
‘‘(c) DEVELOPMENT AND REEVALUATION OF STAFF-
ING PLAN.— 
‘‘(1) CONSIDERATIONS
IN
DEVELOPMENT
OF 
PLAN.—In developing the staffing plan, a hospital 
shall provide for direct care registered nurse-to-pa-
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tient ratios above the minimum direct care reg-
istered nurse-to-patient ratios required under sub-
section (b) if appropriate based upon consideration 
of, at minimum, the following factors: 
‘‘(A) The number of patients on a par-
ticular unit on a shift-by-shift basis. 
‘‘(B) The acuity level and nursing care 
plan of patients on a particular unit on a shift- 
by-shift basis. 
‘‘(C) The anticipated admissions, dis-
charges, and transfers of patients during each 
shift that impacts direct patient care. 
‘‘(D) Specialized experience required of di-
rect care registered nurses on a particular unit. 
‘‘(E) Staffing levels and services provided 
by licensed vocational or practical nurses, li-
censed psychiatric technicians, certified nurse 
assistants, or other ancillary staff in meeting 
direct patient care needs not required by a di-
rect care registered nurse. 
‘‘(F) The level of familiarity with hospital 
practices, policies, and procedures by temporary 
agency direct care registered nurses used dur-
ing a shift. 
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‘‘(G) Obstacles to efficiency in the delivery 
of patient care presented by physical layout. 
‘‘(2) DOCUMENTATION OF STAFFING.—A hos-
pital shall specify the system used to document ac-
tual staffing in each unit for each shift. 
‘‘(3) ANNUAL REEVALUATION OF PLAN.— 
‘‘(A) IN GENERAL.—A hospital shall annu-
ally evaluate its staffing plan in each unit in re-
lation to actual patient care requirements. 
‘‘(B) UPDATE.—A hospital shall update its 
staffing plan to the extent appropriate based on 
such evaluation. 
‘‘(4) TRANSPARENCY.— 
‘‘(A) IN GENERAL.—Any staffing plan or 
method used to create and evaluate acuity-level 
and adopted by a hospital under this section 
shall be transparent in all respects, including 
disclosure of detailed documentation of the 
methodology used to determine nursing staff-
ing, identifying each factor, assumption, and 
value used in applying such methodology. 
‘‘(B) PUBLIC
AVAILABILITY.—The Sec-
retary shall establish procedures to provide that 
the documentation submitted under subsection 
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(d) is available for public inspection in its en-
tirety. 
‘‘(5) REGISTERED
NURSE
PARTICIPATION.—A 
staffing plan of a hospital— 
‘‘(A) shall be developed and subsequent re-
evaluations shall be conducted under this sub-
section on the basis of input from direct care 
registered nurses at the hospital from each unit 
or patient care area; and 
‘‘(B) where such nurses are represented 
through collective bargaining, shall require bar-
gaining with the applicable recognized or cer-
tified collective bargaining representative of 
such nurses. 
Nothing in this title shall be construed to permit 
conduct prohibited under the National Labor Rela-
tions Act (29 U.S.C. 151 et seq.) or chapter 71 of 
title 5, United States Code. 
‘‘(6) STAFFING
COMMITTEES.—If a hospital 
maintains a staffing committee, then the committee 
shall include at least one registered nurse from each 
hospital unit and shall be composed of at least 50 
percent direct care registered nurses. The staffing 
committee shall include meaningful representation of 
other direct care nonmanagement staff. Direct care 
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registered nurses who serve on the committee shall 
be selected by other direct care registered nurses 
from their unit. Other direct care nonmanagement 
staff shall be selected by other direct care non-
management staff. Participation on staffing commit-
tees shall be considered a part of the employee’s reg-
ularly scheduled workweek. 
‘‘(d) SUBMISSION OF PLAN TO SECRETARY.—A hos-
pital shall submit to the Secretary its staffing plan and 
any annual updates under subsection (c)(3)(B). A feder-
ally operated hospital may submit its staffing plan 
through the department or agency operating the hospital. 
‘‘SEC. 3402. POSTING, RECORDS, AND AUDITS. 
‘‘(a) POSTING REQUIREMENTS.—In each unit, a hos-
pital shall post a uniform notice in a form specified by 
the Secretary in regulation that— 
‘‘(1) explains requirements imposed under sec-
tion 3401; 
‘‘(2) includes actual direct care registered 
nurse-to-patient ratios during each shift; 
‘‘(3) includes the actual number and titles of di-
rect care registered nurses assigned during each 
shift; and 
‘‘(4) is visible, conspicuous, and accessible to 
staff, patients, and the public. 
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‘‘(b) RECORDS.— 
‘‘(1) MAINTENANCE OF RECORDS.—Each hos-
pital shall maintain accurate records of actual direct 
care registered nurse-to-patient ratios in each unit 
for each shift for no less than 3 years. Such records 
shall include— 
‘‘(A) the number of patients in each unit; 
‘‘(B) the identity and duty hours of— 
‘‘(i) each direct care registered nurse 
assigned to each patient in each unit in 
each shift; and 
‘‘(ii) ancillary staff who are under the 
coordination of the direct care registered 
nurse; 
‘‘(C) certification that each nurse received 
rest and meal breaks and the identity and duty 
hours of each direct care registered nurse who 
provided such relief; and 
‘‘(D) a copy of each notice posted under 
subsection (a). 
‘‘(2) AVAILABILITY
OF
RECORDS.—Each hos-
pital shall make its records maintained under para-
graph (1) available to— 
‘‘(A) the Secretary; 
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‘‘(B) registered nurses and their collective 
bargaining representatives (if any); and 
‘‘(C) the public under regulations estab-
lished by the Secretary, or in the case of a fed-
erally operated hospital, under section 552 of 
title 5, United States Code (commonly known 
as the Freedom of Information Act). 
‘‘(c) AUDITS.—The Secretary shall conduct periodic 
audits to ensure— 
‘‘(1) implementation of the staffing plan in ac-
cordance with this title; and 
‘‘(2) accuracy in records maintained under this 
section. 
‘‘SEC. 3403. MINIMUM DIRECT CARE LICENSED PRACTICAL 
NURSE STAFFING REQUIREMENTS. 
‘‘(a) ESTABLISHMENT.—A hospital’s staffing plan 
shall comply with minimum direct care licensed practical 
nurse staffing requirements that the Secretary establishes 
for units in hospitals. Such staffing requirements shall be 
established not later than 18 months after the date of the 
enactment of this title, and shall be based on the study 
conducted under subsection (b). 
‘‘(b) STUDY.—Not later than 1 year after the date 
of the enactment of this title, the Secretary, acting 
through the Director of the Agency for Healthcare Re-
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search and Quality, shall complete a study of licensed 
practical nurse staffing and its effects on patient care in 
hospitals. The Director may contract with a qualified enti-
ty or organization to carry out such study under this para-
graph. The Director shall consult with licensed practical 
nurses and organizations representing licensed practical 
nurses regarding the design and conduct of the study. 
‘‘(c) APPLICATION OF REGISTERED NURSE PROVI-
SIONS TO LICENSED PRACTICAL NURSE STAFFING RE-
QUIREMENTS.—Paragraphs (2), (4)(A), (4)(B), (4)(C), 
and (6) of section 3401(b), paragraphs (1), (2), (3), and 
(4) of section 3401(c), and section 3402 shall apply to 
the establishment and application of direct care licensed 
practical nurse staffing requirements under this section 
pursuant to the additional staffing requirements under 
subsection (b)(3)(G) of section 3401 and in the same man-
ner that they apply to the establishment and application 
of direct care registered nurse-to-patient ratios under sec-
tions 3401 and 3402. 
‘‘(d) EFFECTIVE DATE.—The requirements of this 
section shall take effect as soon as practicable, as deter-
mined by the Secretary, but not later than— 
‘‘(1) 2 years after the date of the enactment of 
this title; and 
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‘‘(2) in the case of a hospital in a rural area 
(as defined in section 1886(d)(2)(D) of the Social 
Security Act), 4 years after the date of the enact-
ment of this title. 
‘‘(e) STUDY.—Not later than 1 year after the date 
of the enactment of this title, the Secretary, acting 
through the Director of the Agency for Healthcare Re-
search and Quality shall complete a study of registered 
and practical nurse staffing requirements in clinics and 
other outpatient settings, and its effects on patient care 
in outpatient settings. The Director may contract with a 
qualified entity or organization to carry out such study 
under this subsection. The Director shall consult with reg-
istered nurses and licensed practice nurses working in out-
patient settings, including professional nursing associa-
tions and labor organizations representing both registered 
and practice nurses working in outpatient settings regard-
ing the design and conduct of the study. 
‘‘SEC. 3404. ADJUSTMENT IN REIMBURSEMENT. 
‘‘(a) MEDICARE REIMBURSEMENT.—The Secretary 
shall adjust payments made to hospitals (other than feder-
ally operated hospitals) under title XVIII of the Social Se-
curity Act in an amount equal to the net amount of addi-
tional costs incurred in providing services to Medicare 
beneficiaries that are attributable to compliance with re-
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quirements imposed under sections 3401 through 3403. 
The amount of such payment adjustments shall take into 
account recommendations contained in the report sub-
mitted by the Medicare Payment Advisory Commission 
under subsection (c). 
‘‘(b) AUTHORIZATION OF APPROPRIATION FOR FED-
ERALLY OPERATED HOSPITALS.—There are authorized to 
be appropriated such additional sums as are required for 
federally operated hospitals to comply with the additional 
requirements established under sections 3401 through 
3403. 
‘‘(c) MEDPAC REPORT.—Not later than 2 years after 
the date of the enactment of this title, the Medicare Pay-
ment Advisory Commission (established under section 
1805 of the Social Security Act) shall submit to Congress 
and the Secretary a report estimating total costs and sav-
ings attributable to compliance with requirements imposed 
under sections 3401 through 3403. Such report shall in-
clude recommendations on the need, if any, to adjust reim-
bursement for Medicare payments under subsection (a). 
‘‘SEC. 3405. WHISTLEBLOWER AND PATIENT PROTECTIONS. 
‘‘(a) PROFESSIONAL OBLIGATION AND RIGHTS.—All 
nurses have a duty and right to act based on their profes-
sional judgment in accordance with State nursing laws 
and regulations of the State in which the direct nursing 
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care is being performed and to provide care in the exclu-
sive interests of the patients and to act as the patient’s 
advocate. 
‘‘(b) ACCEPTANCE
OF
PATIENT
CARE
ASSIGN-
MENTS.—The nurse is responsible for providing com-
petent, safe, therapeutic, and effective nursing care to as-
signed patients. Before accepting a patient assignment, a 
nurse shall— 
‘‘(1) have the necessary professional knowledge, 
judgment, skills, and ability to provide the required 
care; 
‘‘(2) determine using professional judgment in 
accordance with State nursing laws and regulations 
of the State in which the direct nursing care is being 
performed whether the nurse is competent to per-
form the nursing care required; and 
‘‘(3) determine whether acceptance of a patient 
assignment would expose the patient or nurse to risk 
of harm. 
‘‘(c) OBJECTION TO OR REFUSAL OF ASSIGNMENT.— 
A nurse may object to, or refuse to participate in, any 
activity, policy, practice, assignment, or task if in good 
faith— 
‘‘(1) the nurse reasonably believes it to be in 
violation of section 3401 or 3403; or 
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‘‘(2) the nurse is not prepared by education, 
training, or experience to fulfill the assignment with-
out compromising the safety of any patient or jeop-
ardizing the license of the nurse. 
‘‘(d) RETALIATION FOR OBJECTION TO OR REFUSAL 
OF ASSIGNMENT BARRED.— 
‘‘(1) NO DISCHARGE, DISCRIMINATION, OR RE-
TALIATION.—No hospital shall discharge, retaliate, 
discriminate, or otherwise take adverse action in any 
manner with respect to any aspect of a nurse’s em-
ployment (as defined in section 3407), including dis-
charge, promotion, compensation, or terms, condi-
tions, or privileges of employment, based on the 
nurse’s refusal of a work assignment under sub-
section (c). 
‘‘(2) NO FILING OF COMPLAINT.—No hospital 
shall file a complaint or a report against a nurse 
with a State professional disciplinary agency because 
of the nurse’s refusal of a work assignment under 
subsection (c). 
‘‘(e) CAUSE OF ACTION.—Any nurse, collective bar-
gaining representative, or legal representative of any nurse 
who has been discharged, discriminated against, or retali-
ated against in violation of subsection (d)(1) or against 
whom a complaint or report has been filed in violation of 
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subsection (d)(2) may (without regard to whether a com-
plaint has been filed under subsection (f) of this section 
or subsection (b) of section 3406) bring a cause of action 
in a United States district court. A nurse who prevails 
on the cause of action shall be entitled to one or more 
of the following: 
‘‘(1) Reinstatement. 
‘‘(2) Reimbursement of lost wages, compensa-
tion, and benefits. 
‘‘(3) Attorneys’ fees. 
‘‘(4) Court costs. 
‘‘(5) Other damages. 
‘‘(f) COMPLAINT TO SECRETARY.—A nurse, patient, 
collective bargaining representative, or other individual 
may file a complaint with the Secretary against a hospital 
that violates the provisions of this title. For any complaint 
filed, the Secretary shall— 
‘‘(1) receive and investigate the complaint; 
‘‘(2) determine whether a violation of this title 
as alleged in the complaint has occurred; and 
‘‘(3) if such a violation has occurred, issue an 
order that the complaining nurse or individual shall 
not suffer any discharge, retaliation, discrimination, 
or other adverse action prohibited by subsection (d) 
or subsection (h). 
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‘‘(g) TOLL-FREE TELEPHONE NUMBER.— 
‘‘(1) IN GENERAL.—The Secretary shall provide 
for the establishment of a toll-free telephone hotline 
to provide information regarding the requirements 
under section 3401 through 3403 and to receive re-
ports of violations of such section. 
‘‘(2) NOTICE TO PATIENTS.—A hospital shall 
provide each patient admitted to the hospital for in-
patient care with the hotline described in paragraph 
(1), and shall give notice to each patient that such 
hotline may be used to report inadequate staffing or 
care. 
‘‘(h) PROTECTION FOR REPORTING.— 
‘‘(1) PROHIBITION
ON
RETALIATION
OR
DIS-
CRIMINATION.—A hospital shall not discriminate or 
retaliate in any manner against any patient, em-
ployee, or contract employee of the hospital, or any 
other individual, on the basis that such individual, in 
good faith, individually or in conjunction with an-
other person or persons, has presented a grievance 
or complaint, or has initiated or cooperated in any 
investigation or proceeding of any governmental en-
tity, regulatory agency, or private accreditation 
body, made a civil claim or demand, or filed an ac-
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tion relating to the care, services, or conditions of 
the hospital or of any affiliated or related facilities. 
‘‘(2) GOOD FAITH DEFINED.—For purposes of 
this subsection, an individual shall be deemed to be 
acting in good faith if the individual reasonably be-
lieves— 
‘‘(A) the information reported or disclosed 
is true; and 
‘‘(B) a violation of this title has occurred 
or may occur. 
‘‘(i) 
PROHIBITION
ON
INTERFERENCE
WITH 
RIGHTS.— 
‘‘(1) EXERCISE OF RIGHTS.—It shall be unlaw-
ful for any hospital to— 
‘‘(A) interfere with, restrain, or deny the 
exercise, or attempt to exercise, by any person 
of any right provided or protected under this 
title; or 
‘‘(B) coerce or intimidate any person re-
garding the exercise or attempt to exercise such 
right. 
‘‘(2) OPPOSITION TO UNLAWFUL POLICIES OR 
PRACTICES.—It shall be unlawful for any hospital to 
discriminate or retaliate against any person for op-
posing any hospital policy, practice, or actions which 
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are alleged to violate, breach, or fail to comply with 
any provision of this title. 
‘‘(3) PROHIBITION
ON
INTERFERENCE
WITH 
PROTECTED COMMUNICATIONS.—A hospital (or an 
individual representing a hospital) shall not make, 
adopt, or enforce any rule, regulation, policy, or 
practice which in any manner directly or indirectly 
prohibits, impedes, or discourages a direct care 
nurse from, or intimidates, coerces, or induces a di-
rect care nurse regarding, engaging in free speech 
activities or disclosing information as provided under 
this title. 
‘‘(4) PROHIBITION
ON
INTERFERENCE
WITH 
COLLECTIVE ACTION.—A hospital (or an individual 
representing a hospital) shall not in any way inter-
fere with the rights of nurses to organize, bargain 
collectively, and engage in concerted activity under 
section 7 of the National Labor Relations Act (29 
U.S.C. 157). 
‘‘(j) NOTICE.—A hospital shall post in an appropriate 
location in each unit a conspicuous notice in a form speci-
fied by the Secretary that— 
‘‘(1) explains the rights of nurses, patients, and 
other individuals under this section; 
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‘‘(2) includes a statement that a nurse, patient, 
or other individual may file a complaint with the 
Secretary against a hospital that violates the provi-
sions of this title; and 
‘‘(3) provides instructions on how to file such a 
complaint. 
‘‘(k) EFFECTIVE DATE.— 
‘‘(1) REFUSAL; RETALIATION; CAUSE
OF
AC-
TION.— 
‘‘(A) 
IN
GENERAL.—Subsections 
(c) 
through (e) shall apply to objections and refus-
als occurring on or after the effective date of 
the provision of this title to which the objection 
or refusal relates. 
‘‘(B) EXCEPTION.—Subsection (c)(2) shall 
not apply to objections or refusals in any hos-
pital before the requirements of section 3401(a) 
or 3403(a), as applicable, apply to that hos-
pital. 
‘‘(2) PROTECTIONS
FOR
REPORTING.—Sub-
section (h)(1) shall apply to actions occurring on or 
after the effective date of the provision to which the 
violation relates, except that such subsection shall 
apply to initiation, cooperation, or participation in 
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an investigation or proceeding on or after the date 
of enactment of this title. 
‘‘(3) NOTICE.—Subsection (j) shall take effect 
18 months after the date of enactment of this title. 
‘‘SEC. 3406. ENFORCEMENT. 
‘‘(a) IN GENERAL.—The Secretary shall enforce the 
requirements and prohibitions of this title in accordance 
with this section. 
‘‘(b) PROCEDURES
FOR RECEIVING
AND INVES-
TIGATING COMPLAINTS.—The Secretary shall establish 
procedures under which— 
‘‘(1) any person may file a complaint alleging 
that a hospital has violated a requirement or a pro-
hibition of this title; and 
‘‘(2) such complaints shall be investigated by 
the Secretary. 
‘‘(c) REMEDIES.—If the Secretary determines that a 
hospital has violated a requirement of this title, the Sec-
retary— 
‘‘(1) shall require the facility to establish a cor-
rective action plan to prevent the recurrence of such 
violation; and 
‘‘(2) may impose civil money penalties, as de-
scribed in subsection (d). 
‘‘(d) CIVIL PENALTIES.— 
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‘‘(1) IN GENERAL.—In addition to any other 
penalties prescribed by law, the Secretary may im-
pose civil penalties as follows: 
‘‘(A) HOSPITAL LIABILITY.—The Secretary 
may impose on a hospital found to be in viola-
tion of this title a civil money penalty of— 
‘‘(i) not more than $25,000 for the 
first knowing violation of this title by such 
hospital; and 
‘‘(ii) not more than $50,000 for any 
subsequent knowing violation of this title 
by such hospital. 
‘‘(B) INDIVIDUAL
LIABILITY.—The Sec-
retary may impose on an individual who— 
‘‘(i) is employed by a hospital found 
by the Secretary to have violated this title; 
and 
‘‘(ii) knowingly violates this title, 
a civil money penalty of not more than $20,000 
for each such violation by the individual. 
‘‘(2) PROCEDURES.—The provisions of section 
1128A of the Social Security Act (other than sub-
sections (a) and (b)) shall apply with respect to a 
civil money penalty or proceeding under this sub-
section in the same manner as such provisions apply 
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with respect to a civil money penalty or proceeding 
under such section 1128A. 
‘‘(e) PUBLIC NOTICE OF VIOLATIONS.— 
‘‘(1) INTERNET WEBSITE.—The Secretary shall 
publish on the internet website of the Department of 
Health and Human Services the names of hospitals 
on which a civil money penalty has been imposed 
under this section, the violation for which such pen-
alty was imposed, and such additional information 
as the Secretary determines appropriate. 
‘‘(2) CHANGE OF OWNERSHIP.—With respect to 
a hospital that had a change of ownership, as deter-
mined by the Secretary, penalties imposed on the 
hospital while under previous ownership shall no 
longer be published by the Secretary pursuant to 
paragraph (1) after the 1-year period beginning on 
the date of change of ownership. 
‘‘(f) USE OF FUNDS.—Funds collected by the Sec-
retary pursuant to this section are authorized to be appro-
priated to carry out this title. 
‘‘SEC. 3407. DEFINITIONS. 
‘‘For purposes of this title: 
‘‘(1) ACUITY LEVEL.—The term ‘acuity level’ 
means the determination, using a hospital acuity 
measurement tool that has been developed and es-
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tablished in coordination with direct care registered 
nurses and made transparent pursuant to section 
3401(c)(4), of nursing care requirements, based on 
the assigned direct care registered nurse’s profes-
sional judgment of— 
‘‘(A) the severity and complexity of an in-
dividual patient’s illness or injury; 
‘‘(B) the need for specialized equipment; 
and 
‘‘(C) the intensity of nursing interventions 
required. 
‘‘(2) COMPETENCE.—The term ‘competence’ or 
‘competent’ means the satisfactory application of the 
duties and responsibilities of a registered nurse in 
providing nursing care to specific patient popu-
lations and for acuity levels for each patient care 
unit or area pursuant to the State nursing laws and 
regulations of the State in which the direct nursing 
care is being performed. 
‘‘(3) 
DIRECT
CARE
LICENSED
PRACTICAL 
NURSE.—The term ‘direct care licensed practical 
nurse’ means an individual who has been granted a 
license by at least one State to practice as a licensed 
practical nurse or a licensed vocational nurse and 
who provides bedside care for one or more patients. 
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‘‘(4) DIRECT CARE REGISTERED NURSE.—The 
term ‘direct care registered nurse’ means an indi-
vidual who has been granted a license by at least 
one State to practice as a registered nurse and who 
provides bedside care for one or more patients. 
‘‘(5) EMPLOYMENT.—The term ‘employment’ 
includes the provision of services under a contract or 
other arrangement. 
‘‘(6) HOSPITAL.—The term ‘hospital’ has the 
meaning given that term in section 1861(e) of the 
Social Security Act, and includes a hospital that is 
operated by the Department of Veterans Affairs, the 
Department of Defense, the Indian Health Services 
Program, or any other department or agency of the 
United States. 
‘‘(7) NURSE.—The term ‘nurse’ means any di-
rect care registered nurse or direct care licensed 
practice nurse (as the case may be), regardless of 
whether or not the nurse is an employee. 
‘‘(8) NURSING CARE PLAN.—The term ‘nursing 
care plan’ means a plan developed by the assigned 
direct care registered nurse (in accordance with 
nursing law in the State in which the nursing care 
is performed) that indicates the nursing care to be 
given to individual patients that— 
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‘‘(A) considers the acuity level of the pa-
tient; 
‘‘(B) is developed in coordination with the 
patient, the patient’s family, or other represent-
atives when appropriate, and staff of other dis-
ciplines involved in the care of the patient; 
‘‘(C) reflects all elements of the nursing 
process; and 
‘‘(D) recommends the number and skill 
mix of additional licensed and unlicensed direct 
care staff needed to fully implement the nursing 
care plan. 
‘‘(9) PROFESSIONAL
JUDGMENT.—The term 
‘professional judgment’ means, in accordance with 
State nursing laws and regulations of the State in 
which the direct nursing care is being performed, the 
direct care registered nurse’s application of knowl-
edge, expertise, and experience in conducting a com-
prehensive nursing assessment of each patient and 
in making independent decisions about patient care 
including the need for additional staff. 
‘‘(10) STAFFING
PLAN.—The term ‘staffing 
plan’ means a staffing plan required under section 
3401. 
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‘‘(11) STATE OF EMERGENCY.—The term ‘state 
of emergency’— 
‘‘(A) means a state of emergency that is 
an unpredictable or unavoidable occurrence at 
an unscheduled or unpredictable interval, relat-
ing to health care delivery and requiring imme-
diate medical interventions and care; and 
‘‘(B) does not include a state of emergency 
that results from a labor dispute in the health 
care industry or consistent understaffing. 
‘‘SEC. 3408. RULE OF CONSTRUCTION. 
‘‘Nothing in this title shall be construed to authorize 
disclosure of private and confidential patient information, 
if such disclosure is not authorized or required by other 
applicable law.’’. 
(b) RECOMMENDATIONS TO CONGRESS.—Not later 
than 1 year after the date of enactment of this Act, the 
Secretary of Health and Human Services shall submit to 
Congress a report containing recommendations for ensur-
ing that sufficient numbers of nurses are available to meet 
the requirements imposed by title XXXIV of the Public 
Health Service Act, as added by subsection (a). 
(c) REPORT BY HRSA.— 
(1) IN GENERAL.—Not later than 2 years after 
the date of enactment of this Act, the Administrator 
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