I 
108TH CONGRESS 
1ST SESSION 
H. R. 745
To amend title XVIII of the Social Security Act to provide for patient 
protection by limiting the number of mandatory overtime hours a nurse 
may be required to work in certain providers of services to which pay-
ments are made under the Medicare Program. 
IN THE HOUSE OF REPRESENTATIVES 
FEBRUARY 12, 2003
Mr. STARK (for himself, Mr. LATOURETTE, Mr. RANGEL, Mr. KLECZKA, Mr. 
WAXMAN, Mr. PALLONE, Ms. DEGETTE, Mr. SERRANO, Mr. SIMMONS, 
Mr. TOWNS, Mr. WEINER, Ms. LEE, Ms. LOFGREN, Ms. SCHAKOWSKY, 
Mr. MOORE, Ms. NORTON, Ms. WOOLSEY, Mr. FROST, Mr. OWENS, Mr. 
KILDEE, Ms. DELAURO, Mr. SANDERS, Mrs. CHRISTENSEN, Mr. 
GRIJALVA, Mr. LYNCH, Mr. FRANK of Massachusetts, Mr. LANGEVIN, 
Mrs. CAPPS, Mr. MEEHAN, Mr. FILNER, Mr. HINCHEY, Mr. INSLEE, Mr. 
MCDERMOTT, Mr. WEXLER, Mr. NADLER, Mr. GORDON, Mr. BISHOP of 
New York, Mr. GUTIERREZ, Mr. SANDLIN, Ms. KILPATRICK, Mr. 
CARDIN, Mr. ANDREWS, Mr. CARSON of Oklahoma, Mr. DAVIS of Illinois, 
Mr. KUCINICH, and Mr. HOLT) introduced 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 de-
termined 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 provide 
for patient protection by limiting the number of manda-
tory overtime hours a nurse may be required to work 
in certain providers of services to which payments are 
made under the Medicare Program.
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 ‘‘Safe Nursing and Pa-
tient Care Act of 2003’’.
SEC. 2. FINDINGS. 
The Congress finds as follows: 
(1) The Federal Government has a substantial 
interest in assuring that delivery of health care serv-
ices to patients in health care facilities is adequate 
and safe. 
(2) Research, including a recent study pub-
lished in the October 23–30, 2002 issue of the Jour-
nal of the American Medical Association (JAMA), 
documents that higher nurse staffing levels result in 
better patient outcomes, yet health care providers re-
port substantial difficulties in recruiting and retain-
ing sufficient nursing staff, as evidenced by the ap-
proximately 500,000 licensed nurses who are not 
practicing nursing. 
(3) While job dissatisfaction and overtime work 
are contributing to the departure of nurses from 
their profession, as highlighted by a recent report of 
the Comptroller General of the United States, health
care providers continue to make use of mandatory 
overtime as a staffing method. 
(4) The widespread practice of requiring nurses 
to work extended shifts and forego days off causes 
nurses to frequently provide care in a state of fa-
tigue, contributing to medical errors and other con-
sequences that compromise patient safety. 
(5) Limitations on mandatory overtime will en-
sure that health care facilities throughout the coun-
try operate in a manner that safeguards public safe-
ty and guarantees the delivery of quality health care 
services and facilitates the retention and recruitment 
of nurses. 
SEC. 3. LIMITATIONS ON MANDATORY OVERTIME FOR 
NURSES. 
(a) PROVIDER AGREEMENTS.—Section 1866 of the 
Social Security Act (42 U.S.C. 1395cc) is amended—
(1) in subsection (a)(1)—
(A) in subparagraph (R), by striking 
‘‘and’’ at the end; 
(B) in subparagraph (S), by striking the 
period and inserting ‘‘, and’’; and 
(C) by inserting after subparagraph (S), 
the following:
‘‘(T) to comply with the requirements of sub-
section (j) (relating to limitations on mandatory 
overtime for nurses).’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(j) LIMITATIONS ON MANDATORY OVERTIME FOR 
NURSES.—For purposes of subsection (a)(1)(T), the re-
quirements of this subsection are the following: 
‘‘(1) PROHIBITION
ON
MANDATORY
OVER-
TIME.—Except as provided in this subsection, a pro-
vider of services shall not, directly or indirectly, re-
quire a nurse to work in excess of any of the fol-
lowing: 
‘‘(A) The scheduled work shift or duty pe-
riod of the nurse. 
‘‘(B) 12 hours in a 24-hour period. 
‘‘(C) 80 hours in a consecutive 14-day pe-
riod. 
‘‘(2) EXCEPTIONS.—
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), the requirements of paragraph (1) 
shall not apply to a provider of services during 
a declared state of emergency if the provider is 
requested, or otherwise is expected, to provide
an exceptional level of emergency or other med-
ical services to the community. 
‘‘(B) LIMITATIONS.—With respect to a 
provider of services to which subparagraph (A) 
applies, a nurse may only be required to work 
for periods in excess of the periods described in 
paragraph (1) if—
‘‘(i) the provider has made reasonable 
efforts to fill the immediate staffing needs 
of the provider through alternative means; 
and 
‘‘(ii) the duration of the work require-
ment does not extend past the earlier of—
‘‘(I) the date on which the de-
clared state of emergency ends; or 
‘‘(II) the date on which the pro-
vider’s direct role in responding to the 
medical needs resulting from the de-
clared state of emergency ends. 
‘‘(3) REPORT OF VIOLATIONS.—
‘‘(A) RIGHT TO REPORT.—
‘‘(i) IN GENERAL.—A nurse may file a 
complaint with the Secretary against a 
provider of services who violates the provi-
sions of this subsection.
‘‘(ii) 
PROCEDURE.—The 
Secretary 
shall establish a procedure under which a 
nurse may file a complaint under clause 
(i). 
‘‘(B) INVESTIGATION
OF
COMPLAINT.—
The Secretary shall investigate complaints of 
violations filed by a nurse under subparagraph 
(A).
‘‘(C) ACTIONS.—If the Secretary deter-
mines that a provider of services has violated 
the provisions of this subsection, the Secretary 
shall require the provider to establish a plan of 
action to eliminate the occurrence of such viola-
tion, and may seek civil money penalties under 
paragraph (7). 
‘‘(4) 
NURSE
NONDISCRIMINATION
PROTEC-
TIONS.—
‘‘(A) IN GENERAL.—A provider of services 
shall not penalize, discriminate, or retaliate in 
any manner with respect to any aspect of em-
ployment, including discharge, promotion, com-
pensation, or terms, conditions, or privileges of 
employment against a nurse who refuses to 
work mandatory overtime or who in good faith,
individually or in conjunction with another per-
son or persons—
‘‘(i) reports a violation or suspected 
violation of this subsection to a public reg-
ulatory agency, a private accreditation 
body, or the management personnel of the 
provider of services; 
‘‘(ii) initiates, cooperates, or otherwise 
participates in an investigation or pro-
ceeding brought by a regulatory agency or 
private accreditation body concerning mat-
ters covered by this subsection; or 
‘‘(iii) informs or discusses with other 
employees, with representatives of those 
employees, or with representatives of asso-
ciations of health care professionals, viola-
tions or suspected violations of this sub-
section. 
‘‘(B) RETALIATORY
REPORTING.—A pro-
vider of services may not file a complaint or a 
report against a nurse with the appropriate 
State professional disciplinary agency because 
the nurse refused to comply with a request to 
work mandatory overtime.
‘‘(C) GOOD FAITH.—For purposes of this 
paragraph, a nurse is deemed to be acting in 
good faith if the nurse reasonably believes—
‘‘(i) that the information reported or 
disclosed is true; and 
‘‘(ii) that a violation has occurred or 
may occur. 
‘‘(5) NOTICE.—
‘‘(A) REQUIREMENT TO POST NOTICE.—
Each provider of services shall post conspicu-
ously in an appropriate location a sign (in a 
form specified by the Secretary) specifying 
rights of nurses under this section. 
‘‘(B) RIGHT TO FILE COMPLAINT.—Such 
sign shall include a statement that a nurse may 
file a complaint with the Secretary against a 
provider of services who violates the provisions 
of this subsection and information with respect 
to the manner of filing such a complaint. 
‘‘(6) POSTING OF NURSE SCHEDULES.—A pro-
vider of services shall regularly post in a conspicuous 
manner the nurse schedules (for such periods of 
time that the Secretary determines appropriate by 
type or class of provider of services) for the depart-
ment or unit involved, and shall make available upon
request to nurses assigned to the department or unit 
the daily nurse schedule for such department or 
unit. 
‘‘(7) CIVIL MONEY PENALTY.—
‘‘(A) IN
GENERAL.—The Secretary may 
impose a civil money penalty of not more than 
$10,000 for each knowing violation of the provi-
sions of this subsection committed by a provider 
of services. 
‘‘(B) PATTERNS
OF
VIOLATIONS.—Not-
withstanding subparagraph (A), the Secretary 
shall provide for the imposition of more severe 
civil money penalties under this paragraph for 
providers of services that establish patterns of 
repeated violations of such provisions. 
‘‘(C) ADMINISTRATION
OF
PENALTIES.—
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 pen-
alty or proceeding under section 1128A(a). 
The Secretary shall publish on the Internet site of 
the Department of Health and Human Services the 
names of providers of services against which civil 
money penalties have been imposed under this para-
graph, the violation for which the penalty was im-
posed, and such additional information as the Sec-
retary determines appropriate. With respect to a 
provider of services that has had a change in owner-
ship, as determined by the Secretary, penalties im-
posed on the provider of services while under pre-
vious ownership shall no longer be published by the 
Secretary on such Internet site after the 1-year pe-
riod beginning on the date of change in ownership. 
‘‘(8) RULE
OF
CONSTRUCTION.—Nothing in 
this subsection shall be construed as precluding a 
nurse from voluntarily working more than any of the 
periods of time described in paragraph (1) so long 
as such work is done consistent with professional 
standards of safe patient care. 
‘‘(9) DEFINITIONS.—In this subsection: 
‘‘(A) MANDATORY OVERTIME.—The term 
‘mandatory overtime’ means hours worked in 
excess of the periods of time described in para-
graph (1), except as provided in paragraph (2), 
pursuant to any request made by a provider of 
services to a nurse which, if refused or declined 
by the nurse involved, may result in an adverse 
employment consequence to the nurse, including 
discharge, discipline, loss of promotion, or retal-
iatory reporting of the nurse to the State pro-
fessional disciplinary agency involved. 
‘‘(B) OVERTIME.—The term ‘overtime’ 
means time worked in excess of the periods of 
time described in paragraph (1). 
‘‘(C) NURSE.—The term ‘nurse’ means a 
registered nurse or a licensed practical nurse. 
‘‘(D) PROVIDER OF SERVICES.—The term 
‘provider of services’ means—
‘‘(i) a hospital, 
‘‘(ii) a hospital outpatient department, 
‘‘(iii) a critical access hospital, 
‘‘(iv) an ambulatory surgical center, 
‘‘(v) a home health agency, 
‘‘(vi) a rehabilitation agency, 
‘‘(vii) a clinic, including a rural health 
clinic, or 
‘‘(viii) a Federally qualified health 
center. 
‘‘(E) DECLARED STATE OF EMERGENCY.—
The term ‘declared state of emergency’ means 
an officially designated state of emergency that 
has been declared by the Federal Government 
or the head of the appropriate State or local 
governmental agency having authority to de-
clare that the State, county, municipality, or lo-
cality is in a state of emergency, but does not 
include a state of emergency that results from 
a labor dispute in the health care industry or 
consistent understaffing. 
‘‘(F) 
STANDARDS
OF
SAFE
PATIENT 
CARE.—The term ‘standards of safe patient 
care’ means the recognized professional stand-
ards governing the profession of the nurse in-
volved.’’.
(b) EFFECTIVE DATE.—The amendments made by 
this section shall take effect 1 year after the date of enact-
ment of this Act. 
SEC. 4. REPORTS. 
(a) STANDARDS
ON SAFE WORKING HOURS
FOR 
NURSES.—
(1) STUDY.—The Secretary of Health and 
Human Services, acting through the Director of the 
Agency for Healthcare Research and Quality, shall 
conduct a study to establish appropriate standards 
for the maximum number of hours that a nurse, who 
furnishes health care to patients, may work without 
compromising the safety of such patients. Such 
standards may vary by provider of service and by de-
partment within a provider of services, by duties or
functions carried out by nurses, by shift, and by 
other factors that the Director determines appro-
priate. The Director may contract with an eligible 
entity or organization to carry out the study under 
this paragraph. 
(2) REPORT.—Not later than 2 years after the 
date of the enactment of this Act, the Secretary 
shall submit to Congress a report on the study con-
ducted under paragraph (1), and shall include rec-
ommendations for such appropriate standards of 
maximum work hours. 
(b) REPORT ON MANDATORY OVERTIME IN FEDER-
ALLY OPERATED MEDICAL FACILITIES.—
(1) STUDY.—
(A) IN GENERAL.—The Director of the Of-
fice of Management and Budget shall conduct 
a study to determine the extent to which feder-
ally operated medical facilities have in effect 
practices and policies with respect to overtime 
requirements for nurses that are inconsistent 
with the provisions of section 1866(j) of the So-
cial Security Act, as added by section 3. 
(B) FEDERALLY OPERATED MEDICAL FA-
CILITIES
DEFINED.—In this subsection, the 
term ‘‘federally operated medical facilities’’
means acute care hospitals, freestanding clinics, 
and home health care clinics that are operated 
by the Department of Veterans Affairs, the De-
partment of Defense, or any other department 
or agency of the United States. 
(2) REPORT.—Not later than 6 months after 
the date of the enactment of this Act, the Director 
of the Office of Management and Budget shall sub-
mit to Congress a report on the study conducted 
under paragraph (1) and shall include recommenda-
tions for the implementation of policies within feder-
ally operated medical facilities with respect to over-
time requirements for nurses that are consistent 
with such section 1866(j), as so added.
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