I 
110TH CONGRESS 
1ST SESSION H. R. 4138 
To amend title XVIII of the Social Security Act to impose minimum nurse 
staffing ratios in Medicare participating hospitals, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
NOVEMBER 9, 2007 
Mrs. CAPPS
(for herself, Ms. GINNY
BROWN-WAITE
of Florida, Mr. 
LATOURETTE, Mr. GRIJALVA, Mrs. MCCARTHY of New York, Ms. 
SCHWARTZ, Mr. HINCHEY, Ms. SCHAKOWSKY, Mr. BISHOP of New York, 
Mr. ABERCROMBIE, Mr. BISHOP of Georgia, Ms. HIRONO, Ms. BALDWIN, 
Mr. SPRATT, Mr. PERLMUTTER, Mr. COHEN, and Mr. DEFAZIO) 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 title XVIII of the Social Security Act to impose 
minimum nurse staffing ratios in Medicare participating 
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, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Registered Nurse Safe 
Staffing Act of 2007’’. 
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SEC. 2. FINDINGS. 
The Congress makes the following findings: 
(1) There are hospitals throughout the United 
States that have inadequate staffing of registered 
nurses to protect the well-being and health of the 
patients. 
(2) Studies show that the health of patients in 
hospitals is directly proportionate to the number of 
registered nurses working in the hospital. 
(3) There is a critical shortage of registered 
nurses in the United States. 
(4) The effect of that shortage is revealed in 
unsafe staffing levels in hospitals. 
(5) Patient safety is adversely affected by these 
unsafe staffing levels, creating a public health crisis. 
(6) Registered nurses are being required to per-
form professional services under conditions that do 
not support quality health care or a healthful work 
environment for registered nurses. 
(7) As a payer for inpatient and outpatient hos-
pital services for individuals entitled to benefits 
under the program established under title XVIII of 
the Social Security Act, the Federal Government has 
a compelling interest in promoting the safety of such 
individuals by requiring any hospital participating in 
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such program to establish minimum safe staffing 
levels for registered nurses. 
SEC. 3. ESTABLISHMENT OF MINIMUM STAFFING RATIOS 
BY MEDICARE PARTICIPATING HOSPITALS. 
(a) REQUIREMENT OF MEDICARE PROVIDER AGREE-
MENT.—Section 1866(a)(1) of the Social Security Act (42 
U.S.C. 1395cc(a)(1)) is amended— 
(1) by striking ‘‘and’’ at the end of subpara-
graph (U); 
(2) by striking the period at the end of sub-
paragraph (V) and inserting ‘‘, and’’; and 
(3) by inserting after subparagraph (V) and be-
fore the end matter the following: 
‘‘(W) in the case of a hospital— 
‘‘(i) to adopt and implement a staffing 
system that meets the requirements of sec-
tion 1898; 
‘‘(ii) to meet the requirements of such 
section relating to— 
‘‘(I) records maintenance; 
‘‘(II) data collection; and 
‘‘(III) data submission; and 
‘‘(iii) to meet the requirements of 
such section relating to non-discrimination 
and retaliation.’’. 
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(b) REQUIREMENTS.—Title XVIII of the Social Secu-
rity Act (42 U.S.C. 1395 et seq.) is amended by adding 
at the end the following: 
‘‘STAFFING REQUIREMENTS FOR MEDICARE 
PARTICIPATING HOSPITALS 
‘‘SEC. 1898. (a) ESTABLISHMENT OF STAFFING SYS-
TEM.—Each participating hospital shall adopt and imple-
ment a staffing system that ensures a number of reg-
istered nurses on each shift and in each unit of the hos-
pital to ensure appropriate staffing levels for patient care. 
A staffing system adopted and implemented under this 
section shall— 
‘‘(1) be developed on the basis of input from 
the direct care-giving registered nurse staff or, 
where nurses are represented, with the applicable 
recognized or certified collective bargaining rep-
resentatives of the registered nurses; 
‘‘(2) be based upon the number of patients and 
the level and variability of intensity of care to be 
provided, with appropriate consideration given to ad-
missions, discharges and transfers during each shift; 
‘‘(3) account for contextual issues affecting 
staffing and the delivery of care, including architec-
ture and geography of the environment and available 
technology; 
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‘‘(4) reflect the level of preparation and experi-
ence of those providing care; 
‘‘(5) account for staffing level effectiveness or 
deficiencies in related health care classifications, in-
cluding but not limited to, certified nurse assistants, 
licensed vocational nurses, licensed psychiatric tech-
nicians, nursing assistants, aides and orderlies; 
‘‘(6) reflect staffing levels recommended by spe-
cialty nursing organizations; 
‘‘(7) 
subject 
to 
subsection 
(b), 
establish 
upwardly adjustable registered nurse-to-patient ra-
tios based upon registered nurses’ assessment of pa-
tient acuity and existing conditions; 
‘‘(8) provide that a registered nurse shall not be 
assigned to work in a particular unit without first 
having established the ability to provide professional 
care in such unit; and 
‘‘(9) be based on methods that assure validity 
and reliability. 
‘‘(b) LIMITATION.—A staffing system adopted and 
implemented pursuant to subsection (a) may not— 
‘‘(1) set registered-nurse levels below those re-
quired by any Federal or State law or regulation; or 
‘‘(2) utilize any minimum registered nurse-to- 
patient ratio established pursuant to subsection 
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(a)(7) as an upper limit on the staffing of the hos-
pital to which such ratio applies. 
‘‘(c) REPORTING, AND RELEASE TO PUBLIC, OF CER-
TAIN STAFFING INFORMATION.— 
‘‘(1) REQUIREMENTS
FOR
HOSPITALS.—Each 
participating hospital shall— 
‘‘(A) post daily for each shift, in a clearly 
visible place, a document that specifies in a uni-
form manner (as prescribed by the Secretary) 
the current number of licensed and unlicensed 
nursing staff directly responsible for patient 
care in each unit of the hospital, identifying 
specifically the number of registered nurses; 
‘‘(B) upon request, make available to the 
public— 
‘‘(i) the nursing staff information de-
scribed in subparagraph (A); and 
‘‘(ii) a detailed written description of 
the staffing system established by the hos-
pital pursuant to subsection (a); and 
‘‘(C) submit to the Secretary in a uniform 
manner (as prescribed by the Secretary) the 
nursing staff information described in subpara-
graph (A) through electronic data submission 
not less frequently than quarterly. 
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‘‘(2) SECRETARIAL
RESPONSIBILITIES.—The 
Secretary shall— 
‘‘(A) make the information submitted pur-
suant to paragraph (1)(C) publicly available, in-
cluding by publication of such information on 
the Internet site of the Department of Health 
and Human Services; and 
‘‘(B) provide for the auditing of such infor-
mation for accuracy as a part of the process of 
determining whether an institution is a hospital 
for purposes of this title. 
‘‘(d) RECORD-KEEPING; DATA COLLECTION; EVAL-
UATION.— 
‘‘(1) 
RECORD-KEEPING.—Each 
participating 
hospital shall maintain for a period of at least 3 
years (or, if longer, until the conclusion of pending 
enforcement activities) such records as the Secretary 
deems necessary to determine to whether the hos-
pital has adopted and implemented a staffing system 
pursuant to subsection (a). 
‘‘(2) DATA
COLLECTION
ON
CERTAIN
OUT-
COMES.—The Secretary shall require the collection, 
maintenance, and submission of data by each par-
ticipating hospital sufficient to establish the link be-
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tween the staffing system established pursuant to 
subsection (a) and— 
‘‘(A) patient acuity from maintenance of 
acuity data through entries on patients’ charts; 
‘‘(B) patient outcomes that are nursing 
sensitive, such as patient falls, adverse drug 
events, injuries to patients, skin breakdown, 
pneumonia, infection rates, upper gastro-
intestinal bleeding, shock, cardiac arrest, length 
of stay, and patient re-admissions; 
‘‘(C) operational outcomes, such as work- 
related injury or illness, vacancy and turnover 
rates, nursing care hours per patient day, on- 
call use, overtime rates, and needle-stick inju-
ries; and 
‘‘(D) patient complaints related to staffing 
levels. 
‘‘(3) EVALUATION.—Each participating hospital 
shall annually evaluate its staffing system and estab-
lished minimum registered nurse staffing ratios to 
assure on-going reliability and validity of the system 
and ratios. The evaluation shall be conducted by a 
joint management-staff committee comprised of at 
least 50 percent of registered nurses who provide di-
rect patient care and where nurses are represented, 
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with the involvement of the applicable recognized or 
certified collective bargaining representatives of the 
registered nurses. 
‘‘(e) ENFORCEMENT.— 
‘‘(1) RESPONSIBILITY.—The Secretary shall en-
force the requirements and prohibitions of this sec-
tion. 
‘‘(2) PROCEDURES FOR RECEIVING AND INVES-
TIGATING COMPLAINTS.—The Secretary shall estab-
lish procedures under which— 
‘‘(A) any person may file a complaint that 
a participating hospital has violated a require-
ment or a prohibition of this section; and 
‘‘(B) such complaints are investigated by 
the Secretary. 
‘‘(3) REMEDIES.—If the Secretary determines 
that a participating hospital has violated a require-
ment of this section, the Secretary— 
‘‘(A) shall require the facility to establish 
a corrective action plan to prevent the recur-
rence of such violation; and 
‘‘(B) may impose civil money penalties 
under paragraph (4). 
‘‘(4) CIVIL MONEY PENALTIES.— 
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‘‘(A) IN
GENERAL.—In addition to any 
other penalties prescribed by law, the Secretary 
may impose a civil money penalty of not more 
than $10,000 for each knowing violation of a 
requirement of this section, except that the Sec-
retary shall impose a civil money penalty of 
more than $10,000 for each such violation in 
the case of a participating hospital that the 
Secretary determines has a pattern or practice 
of such violations (with the amount of such ad-
ditional penalties being determined in accord-
ance with a schedule or methodology specified 
in regulations). 
‘‘(B) PROCEDURES.—The provisions of 
section 1128A (other than subsections (a) and 
(b)) shall apply to a civil money penalty under 
this paragraph in the same manner as such 
provisions apply to a penalty or proceeding 
under section 1128A. 
‘‘(C) PUBLIC NOTICE OF VIOLATIONS.— 
‘‘(i) INTERNET SITE.—The Secretary 
shall publish on the Internet site of the 
Department of Health and Human Serv-
ices the names of participating hospitals on 
which civil money penalties have been im-
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