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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‘‘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-
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 
Payment 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-
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