I 
108TH CONGRESS 
1ST SESSION H. R. 3656
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 
DECEMBER 8, 2003
Mrs. CAPPS 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 determined by the Speaker, 
in each case for consideration of such provisions as fall within the juris-
diction 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 ‘‘Quality Nursing Care 
Act of 2004’’. 
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 
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)), as amended by the Medicare Pre-
scription Drug, Improvement, and Modernization Act of 
2003, 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.’’.
(b) REQUIREMENTS.—Part D of title XVIII of the 
Social Security Act, as amended by the Medicare Prescrip-
tion Drug, Improvement, and Modernization Act of 2003, 
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;
‘‘(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
‘‘(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-
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,
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.—
‘‘(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-
posed under this section, the violation for 
which the penalty was imposed, and such 
additional information as the Secretary de-
termines appropriate. 
‘‘(ii) CHANGE OF OWNERSHIP.—With 
respect to a participating hospital that had 
a change in ownership, as determined by 
the Secretary, penalties imposed on the 
hospital while under previous ownership 
shall no longer be published by the Sec-
retary of such Internet site after the 1-
year period beginning on the date of 
change in ownership. 
‘‘(f) WHISTLE-BLOWER PROTECTIONS.—
‘‘(1) PROHIBITION
OF
DISCRIMINATION
AND 
RETALIATION.—A participating hospital shall not 
discriminate or retaliate in any manner against any 
patient or employee of the hospital because that pa-
tient or employee, or any other person, has pre-
sented a grievance or complaint, or has initiated or 
cooperated in any investigation or proceeding of any 
kind, relating to the staffing system or other re-
quirements and prohibitions of this section. 
‘‘(2) RELIEF FOR PREVAILING EMPLOYEES.—
An employee of a participating hospital who has
been discriminated or retaliated against in employ-
ment in violation of this subsection may initiate judi-
cial action in a United States District Court and 
shall be entitled to reinstatement, reimbursement for 
lost wages and work benefits caused by the unlawful 
acts of the employing hospital. Prevailing employees 
are entitled to reasonable attorney’s fees and costs 
associated with pursuing the case. 
‘‘(3) RELIEF
FOR
PREVAILING
PATIENTS.—A 
patient who has been discriminated or retaliated 
against in violation of this subsection may initiate 
judicial action in a United States District Court. A 
prevailing patient shall be entitled to liquidated 
damages of $5,000 for a violation of this statute in 
addition to any other damages under other applica-
ble statutes, regulations or common law. Prevailing 
patients are entitled to reasonable attorney’s fees 
and costs associated with pursuing the case. 
‘‘(4) LIMITATION ON ACTIONS.—No action may 
be brought under paragraph (2) or (3) more than 2 
years after the discrimination or retaliation with re-
spect to which the action is brought. 
‘‘(5) TREATMENT
OF
ADVERSE
EMPLOYMENT 
ACTIONS.—For purposes of this subsection—
‘‘(A) an adverse employment action shall 
be treated as ‘retaliation or discrimination’; and 
‘‘(B) an adverse employment action in-
cludes—
‘‘(i) the failure to promote an indi-
vidual or provide any other employment-re-
lated benefit for which the individual would 
otherwise be eligible; 
‘‘(ii) an adverse evaluation or decision 
made in relation to accreditation, certifi-
cation, credentialing, or licensing of the in-
dividual; and 
‘‘(iii) a personnel action that is ad-
verse to the individual concerned. 
‘‘(g) RULES OF CONSTRUCTION.—
‘‘(1) RELATIONSHIP TO STATE LAWS.—Nothing 
in this section shall be construed as exempting or re-
lieving any person from any liability, duty, penalty, 
or punishment provided by any present or future law 
of any State or political subdivision of a State, other 
than any such law which purports to require or per-
mit the doing of any act which would be an unlawful 
practice under this title. 
‘‘(2) RELATIONSHIP TO CONDUCT PROHIBITED 
UNDER THE NATIONAL LABOR RELATIONS ACT.—
Nothing in this section shall be construed as permit-
ting conduct prohibited under the National Labor 
Relations Act or under any other federal, State, or 
local collective bargaining law. 
‘‘(h) REGULATIONS.—The Secretary shall promul-
gate such regulations as are appropriate and necessary to 
implement this Act. 
‘‘(i) DEFINITIONS.—For purposes of this section—
‘‘(1) the term ‘participating hospital’ means a 
hospital that has entered into a provider agreement 
under section 1866; 
‘‘(2) the term ‘registered nurse’ means an indi-
vidual who has been granted a license to practice as 
a registered nurse in at least one State; 
‘‘(3) the term ‘unit’ of a hospital is an organi-
zational department or separate geographic area of 
a hospital, such as a burn unit, a labor and delivery 
room, a post-anesthesia service area, an emergency 
department, an operating room, a pediatric unit, a 
step-down or intermediate care unit, a specialty care 
unit, a telemetry unit, a general medical care unit, 
a subacute care unit, and a transitional inpatient 
care unit; 
‘‘(4) a ‘shift’ is a scheduled set of hours or duty 
period to be worked at a participating hospital; and
‘‘(5) a ‘person’ includes one or more individ-
uals, associations, corporations, unincorporated or-
ganizations or labor unions.’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall become effective on January 1, 2005.
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