I 
116TH CONGRESS 
1ST SESSION H. R. 2581 
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 8, 2019 
Ms. SCHAKOWSKY (for herself, Mr. DANNY K. DAVIS of Illinois, Mr. RASKIN, 
Mr. KHANNA, Mr. SHERMAN, Ms. NORTON, Ms. MCCOLLUM, Ms. 
BROWNLEY of California, Ms. LEE of California, Ms. WILSON of Florida, 
Mr. DEFAZIO, Ms. GABBARD, Ms. MOORE, Ms. DELAURO, Ms. CLARKE 
of New York, Ms. BONAMICI, Mr. TAKANO, Mr. BLUMENAUER, Mr. 
RUSH, Mr. POCAN, Ms. KELLY of Illinois, Mrs. DINGELL, Ms. LOFGREN, 
Ms. JAYAPAL, Ms. VELA´ZQUEZ, Mr. COHEN, and Mr. NADLER) intro-
duced 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 require-
ments in hospitals, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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SECTION 1. SHORT TITLE; TABLE OF CONTENTS; FINDINGS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Nurse Staffing Standards for Hospital Patient Safety 
and Quality Care Act of 2019’’. 
(b) TABLE OF CONTENTS.—The table of contents for 
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. 
(c) FINDINGS.—Congress finds the following: 
(1) The Federal Government has a substantial 
interest in promoting quality care and improving the 
delivery of health care services to patients in health 
care facilities in the United States. 
(2) Recent changes in health care delivery sys-
tems that have resulted in higher acuity levels 
among patients in health care facilities increase the 
need for improved quality measures in order to pro-
tect patient care and reduce the incidence of medical 
errors. 
(3) Inadequate and poorly monitored registered 
nurse staffing practices that result in too few reg-
istered nurses providing direct care jeopardize the 
delivery of quality health care services. 
(4) Numerous studies have shown that patient 
outcomes are directly correlated to direct care reg-
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istered nurse staffing levels, including a 2010 
Health Services Research study that concluded that 
implementation of minimum nurse-to-patient staff-
ing ratios in California has led to improved patient 
outcomes and nurse retention and a 2014 Agency 
for Healthcare Research and Quality study that con-
cluded increases in nurse staffing and skill mix lead 
to improved quality and reduced length of stay at no 
additional cost. 
(5) Requirements for direct care registered 
nurse staffing ratios will help address the registered 
nurse shortage in the United States by aiding in re-
cruitment of new registered nurses and improving 
retention of registered nurses who are considering 
leaving direct patient care because of demands cre-
ated by inadequate staffing. 
(6) Establishing adequate minimum direct care 
registered nurse-to-patient ratios that take into ac-
count patient acuity measures will improve the deliv-
ery of quality health care services and guarantee pa-
tient safety. 
(7) Establishing safe staffing standards for di-
rect care registered nurses is a critical component of 
assuring that there is adequate hospital staffing at 
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all levels to improve the delivery of quality care and 
protect patient safety. 
SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE 
STAFFING REQUIREMENT. 
(a) MINIMUM DIRECT CARE REGISTERED NURSE 
STAFFING REQUIREMENTS.—The Public Health Service 
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-
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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) 
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: 
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‘‘(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. 
‘‘(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 
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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 
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. 
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‘‘(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-
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-
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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 
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 
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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-
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-
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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 
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-
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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 
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-
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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). 
‘‘(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. 
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‘‘(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 
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 
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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-
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 
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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. 
‘‘(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-
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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 
(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 
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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 
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; 
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‘‘(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. 
‘‘(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). 
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‘‘(2) AVAILABILITY
OF
RECORDS.—Each hos-
pital shall make its records maintained under para-
graph (1) available to— 
‘‘(A) the Secretary; 
‘‘(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 
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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-
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. 
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‘‘(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 
‘‘(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. 
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