‘‘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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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 
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 
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‘‘(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 
‘‘(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). 
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‘‘(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 
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 
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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). 
‘‘(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 
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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-
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 
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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 
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 
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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; 
‘‘(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) 
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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 
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. 
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‘‘(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.— 
‘‘(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— 
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‘‘(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 
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 
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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-
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 
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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. 
‘‘(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 
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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— 
‘‘(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. 
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‘‘(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. 
‘‘(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, 
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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 
of the Health Resources and Services Administra-
tion, in consultation with the National Health Care 
Workforce Commission, shall submit to Congress a 
report regarding the relationship between nurse 
staffing levels and nurse retention in hospitals. 
(2) UPDATED REPORT.—Not later than 5 years 
after the date of enactment of this Act, the Adminis-
trator of the Health Resources and Services Admin-
istration, in consultation with the National Health 
Care Workforce Commission, shall submit to Con-
gress an update of the report submitted under para-
graph (1). 
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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) in subparagraph (X), by striking ‘‘, and’’ 
and inserting a comma; 
(2) in subparagraph (Y), by striking the period 
at the end and inserting ‘‘, and’’; and 
(3) by inserting after the subparagraph (Y) the 
following new subparagraph: 
‘‘(Z) in the case of a hospital, to comply with 
the provisions of title XXXIV of the Public Health 
Service Act.’’. 
(b) MEDICAID PROGRAM.—Section 1902(a) of the 
Social Security Act (42 U.S.C. 1396a(a)) is amended— 
(1) by striking ‘‘and’’ at the end of paragraph 
(86); 
(2) by striking the period at the end of para-
graph (87)(D) and inserting ‘‘; and’’; and 
(3) by inserting after paragraph (87) the fol-
lowing new paragraph: 
‘‘(88) provide that any hospital that receives a 
payment under such plan comply with the provisions 
of title XXXIV of the Public Health Service Act (re-
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lating to minimum direct care registered nurse staff-
ing requirements).’’. 
(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 paragraphs: 
‘‘(7) In the case of a Department medical facility that 
is a hospital, the hospital shall comply with the provisions 
of title XXXIV of the Public Health Service Act. 
‘‘(8) Nothing either in chapter 74 of this title or in 
section 7106 of title 5 shall preclude enforcement of the 
provisions of title XXXIV of the Public Health Service Act 
with respect to a Department hospital through grievance 
procedures negotiated in accordance with chapter 71 of 
title 5.’’. 
(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: 
‘‘§ 1110c. 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 XXXIV of the Public Health Service Act.’’. 
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