‘‘(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. 3003. 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), (3), (4)(A), and (5) of 
section 3001(b), section 3001(c), and section 3002 shall 
apply to the establishment and application of direct care 
licensed practical nurse staffing requirements under this 
section in the same manner that they apply to the estab-
lishment and application of direct care registered nurse- 
to-patient ratios under section 3001. 
‘‘(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 2 years after 
the date of the enactment of this title, or in the case of 
a hospital in a rural area (as defined in section 
1886(d)(2)(D) of the Social Security Act), not later than 
4 years after the date of the enactment of this title. 
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‘‘SEC. 3004. 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 3001 through 3003. 
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 3001 through 
3003. 
‘‘(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 3001 through 3003. Such report shall in-
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clude recommendations on the need, if any, to adjust reim-
bursement for Medicare payments under subsection (a). 
‘‘SEC. 3005. PROTECTION OF NURSES AND OTHER INDIVID-
UALS. 
‘‘(a) REFUSAL
OF
ASSIGNMENT.—A nurse may 
refuse to accept an assignment as a nurse in a hospital 
if— 
‘‘(1) the assignment would violate section 3001 
or 3003; or 
‘‘(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. 
‘‘(b) RETALIATION FOR REFUSAL OF ASSIGNMENT 
BARRED.— 
‘‘(1) NO DISCHARGE, DISCRIMINATION, OR RE-
TALIATION.—No hospital shall discharge, discrimi-
nate, or retaliate in any manner with respect to any 
aspect of employment (as defined in section 
3006(5)), including discharge, promotion, compensa-
tion, or terms, conditions, or privileges of employ-
ment against a nurse based on the nurse’s refusal of 
a work assignment under subsection (a). 
‘‘(2) NO FILING OF COMPLAINT.—No hospital 
shall file a complaint or a report against a nurse 
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with the appropriate State professional disciplinary 
agency because of the nurse’s refusal of a work as-
signment under subsection (a). 
‘‘(c) CAUSE OF ACTION.—Any nurse who has been 
discharged, discriminated, or retaliated against in viola-
tion of subsection (b)(1) or against whom a complaint has 
been filed in violation of subsection (b)(2) may 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. 
‘‘(d) COMPLAINT TO SECRETARY.—A nurse 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 
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not suffer any retaliation under subsection (b) or 
under subsection (e). 
‘‘(e) PROTECTION FOR REPORTING.— 
‘‘(1) RETALIATION BARRED.—A hospital shall 
not discriminate or retaliate in any manner with re-
spect to any aspect of employment, including hiring, 
discharge, promotion, compensation, or terms, condi-
tions, or privileges of employment against any indi-
vidual who in good faith, individually or in conjunc-
tion with another person or persons— 
‘‘(A) reports a violation or a suspected vio-
lation of this title to the Secretary, a public reg-
ulatory agency, a private accreditation body, or 
the management personnel of the hospital; 
‘‘(B) initiates, cooperates, or otherwise 
participates in an investigation or proceeding 
brought by the Secretary, a public regulatory 
agency, or a private accreditation body con-
cerning matters covered by this title; or 
‘‘(C) informs or discusses with other indi-
viduals or with representatives of hospital em-
ployees a violation or suspected violation of this 
title. 
‘‘(2) GOOD FAITH DEFINED.—For purposes of 
this subsection, an individual shall be deemed to be 
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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. 
‘‘(f) 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 and other in-
dividuals under this section; 
‘‘(2) includes a statement that a nurse or other 
individual may file a complaint with the Secretary 
against a hospital that violates the provisions of this 
title; and 
‘‘(3) provides instructions on how to file a com-
plaint under paragraph (2). 
‘‘(g) EFFECTIVE DATES.— 
‘‘(1) REFUSAL; RETALIATION; CAUSE
OF
AC-
TION.— 
‘‘(A) 
IN
GENERAL.—Subsections 
(a) 
through (c) shall apply to refusals occurring on 
or after the effective date of the provision to 
which the refusal relates. 
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‘‘(B) EXCEPTION.—Subsection (a)(2) shall 
not apply to refusals in any hospital before the 
requirements of section 3001(a) apply to that 
hospital. 
‘‘(2) PROTECTIONS
FOR
REPORTING.—Sub-
section (e) shall apply to actions described in sub-
paragraphs (A) and (C) of subsection (e)(1) occur-
ring on or after the effective date of the provision 
to which the violation relates. Subsection (e) shall 
apply to initiation, cooperation, or participation in 
an investigation or proceeding on or after the date 
of the enactment of this title. 
‘‘(3) NOTICE.—Subsection (f) shall take effect 
18 months after the date of the enactment of this 
title. 
‘‘SEC. 3006. DEFINITIONS. 
‘‘For purposes of this title: 
‘‘(1) ACUITY SYSTEM.—The term ‘acuity sys-
tem’ means an established measurement tool that— 
‘‘(A) predicts nursing care requirements 
for individual patients based on severity of pa-
tient illness, need for specialized equipment and 
technology, intensity of nursing interventions 
required, and the complexity of clinical nursing 
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judgment needed to design, implement, and 
evaluate the patient’s nursing care plan; 
‘‘(B) details the amount of nursing care 
needed, both in number of nurses and in skill 
mix of nursing personnel required, on a daily 
basis, for each patient in a nursing department 
or unit; 
‘‘(C) takes into consideration the patient 
care services provided not only by registered 
nurses but also by direct care licensed practical 
nurses and other health care personnel; and 
‘‘(D) is stated in terms that can be readily 
used and understood by nurses. 
‘‘(2) 
DIRECT
CARE
LICENSED
PRACTICAL 
NURSE.—The term ‘direct care licensed practical 
nurse’ means an individual who has been granted a 
license by at least 1 State to practice as a licensed 
practical nurse or a licensed vocational nurse and 
who provides bedside care for 1 or more patients. 
‘‘(3) NURSE.—The term ‘nurse’ means any di-
rect care registered nurse or direct care licensed 
practical nurse (as the case may be), regardless of 
whether or not the nurse is an employee. 
‘‘(4) DIRECT CARE REGISTERED NURSE.—The 
term ‘direct care registered nurse’ means an indi-
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vidual who has been granted a license by at least 1 
State to practice as a registered nurse and who pro-
vides bedside care for 1 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) STAFFING PLAN.—The term ‘staffing plan’ 
means a staffing plan required under section 3001.’’. 
(b) RECOMMENDATIONS
TO CONGRESS.—No later 
than 1 year after the date of the enactment of this Act, 
the Secretary of Health and Human Services shall submit 
to Congress a report containing recommendations for en-
suring that sufficient numbers of nurses are available to 
meet the requirements imposed by title XXX of the Public 
Health Service Act, as added by subsection (a). 
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SEC. 3. ENFORCEMENT OF REQUIREMENTS THROUGH FED-
ERAL PROGRAMS. 
(a) MEDICARE PROGRAM.—Section 1866(a)(1) of the 
Social Security Act (42 U.S.C. 1395cc(a)(1)) is amend-
ed— 
(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) the fol-
lowing: 
‘‘(W) in the case of a hospital, to comply with 
the provisions of title XXX of the Public Health 
Service Act.’’. 
(b) MEDICAID PROGRAM.—The first sentence of sec-
tion 1902(a) of the Social Security Act (42 U.S.C. 
1396(a)) is amended— 
(1) by striking ‘‘and’’ at the end of paragraph 
(69); 
(2) by striking the period at the end of para-
graph (70) and inserting ‘‘; and’’; and 
(3) by inserting after paragraph (70) the fol-
lowing new paragraph: 
‘‘(71) provide that any hospital receiving pay-
ments under such plan must comply with the provi-
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sions of title XXX of the Public Health Service 
Act.’’. 
(c) HEALTH BENEFITS PROGRAM OF THE DEPART-
MENT OF VETERANS AFFAIRS.—Section 8110(a) of title 
38, United States Code, is amended by adding at the end 
the following new paragraph: 
‘‘(7) In the case of a Department medical facility that 
is a hospital, the hospital shall comply with the provisions 
of title XXX of the Public Health Service Act.’’. 
(d) HEALTH BENEFITS PROGRAM OF THE DEPART-
MENT OF DEFENSE.— 
(1) IN
GENERAL.—Chapter 55 of title 10, 
United States Code, is amended by adding at the 
end the following new section: 
‘‘§ 1110a. Staffing requirements 
‘‘In the case of a facility of the uniformed services 
that is a hospital, the hospital shall comply with the provi-
sions of title XXX of the Public Health Service Act.’’. 
(2) CLERICAL AMENDMENT.—The table of sec-
tions at the beginning of such chapter is amended 
by inserting after the item relating to section 1110 
the following new item: 
‘‘1110a. Staffing requirements.’’. 
(e) INDIAN HEALTH SERVICES PROGRAM.—Title 
VIII of the Indian Health Care Improvement Act (25 
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U.S.C. 1671 et seq.) is amended by adding at the end 
the following new section: 
‘‘SEC. 826. STAFFING REQUIREMENTS. 
‘‘A hospital of the Service shall comply with the provi-
sions of title XXX of the Public Health Service Act.’’. 
Æ 
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