istered nurses assigned to patients in a hospital 
unit during any 1 shift or over any period of 
time for purposes of meeting the requirements 
under this subsection. 
‘‘(B) PROHIBITION
AGAINST
IMPOSITION 
OF MANDATORY OVERTIME REQUIREMENTS.—A 
hospital shall not impose mandatory overtime 
requirements to meet the hospital unit direct 
care registered nurse-to-patient ratios required 
under this subsection. 
‘‘(C) 
RELIEF
DURING
ROUTINE
AB-
SENCES.—A hospital shall ensure that only a 
direct care registered nurse may relieve another 
direct care registered nurse during breaks, 
meals, and other routine, expected absences 
from a hospital unit. 
‘‘(4) ADJUSTMENT OF RATIOS.— 
‘‘(A) IN GENERAL.—If necessary to protect 
patient safety, the Secretary may prescribe reg-
ulations that— 
‘‘(i) increase minimum direct care reg-
istered nurse-to-patient ratios under this 
subsection to further limit the number of 
patients that may be assigned to each di-
rect care nurse; or 
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‘‘(ii) add minimum direct care reg-
istered nurse-to-patient ratios for units not 
referred to in paragraphs (1) and (2). 
‘‘(B) CONSULTATION.—Such regulations 
shall be prescribed after consultation with af-
fected hospitals and registered nurses. 
‘‘(5) RELATIONSHIP
TO
STATE-IMPOSED
RA-
TIOS.—Nothing in this title shall preempt State 
standards that the Secretary determines to be at 
least equivalent to Federal requirements for a staff-
ing plan established under this title. Minimum direct 
care registered nurse-to-patient ratios established 
under this subsection shall not preempt State re-
quirements that the Secretary determines are at 
least equivalent to Federal requirements for a staff-
ing plan established under this title. 
‘‘(6) EXEMPTION IN EMERGENCIES.—The re-
quirements established under this subsection shall 
not apply during a state of emergency if a hospital 
is requested or expected to provide an exceptional 
level of emergency or other medical services. The 
Secretary shall issue guidance to hospitals that de-
scribes situations that constitute a state of emer-
gency for purposes of the exemption under this para-
graph. 
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‘‘(c) DEVELOPMENT AND REEVALUATION OF STAFF-
ING PLAN.— 
‘‘(1) CONSIDERATIONS
IN
DEVELOPMENT
OF 
PLAN.—In developing the staffing plan, a hospital 
shall provide for direct care registered nurse-to-pa-
tient ratios above the minimum direct care reg-
istered nurse-to-patient ratios required under sub-
section (b) if appropriate based upon consideration 
of the following factors: 
‘‘(A) The number of patients and acuity 
level of patients as determined by the applica-
tion of an acuity system (as defined in section 
3406(1)), on a shift-by-shift basis. 
‘‘(B) The anticipated admissions, dis-
charges, and transfers of patients during each 
shift that impacts direct patient care. 
‘‘(C) Specialized experience required of di-
rect care registered nurses on a particular unit. 
‘‘(D) Staffing levels and services provided 
by licensed vocational or practical nurses, li-
censed psychiatric technicians, certified nurse 
assistants, or other ancillary staff in meeting 
direct patient care needs not required by a di-
rect care registered nurse. 
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‘‘(E) The level of technology available that 
affects the delivery of direct patient care. 
‘‘(F) The level of familiarity with hospital 
practices, policies, and procedures by temporary 
agency direct care registered nurses used dur-
ing a shift. 
‘‘(G) Obstacles to efficiency in the delivery 
of patient care presented by physical layout. 
‘‘(2) DOCUMENTATION OF STAFFING.—A hos-
pital shall specify the system used to document ac-
tual staffing in each unit for each shift. 
‘‘(3) ANNUAL
REEVALUATION
OF
PLAN
AND 
ACUITY SYSTEM.— 
‘‘(A) IN GENERAL.—A hospital shall annu-
ally evaluate— 
‘‘(i) its staffing plan in each unit in 
relation to actual patient care require-
ments; and 
‘‘(ii) the accuracy of its acuity system. 
‘‘(B) UPDATE.—A hospital shall update its 
staffing plan and acuity system to the extent 
appropriate based on such evaluation. 
‘‘(4) TRANSPARENCY.— 
‘‘(A) IN GENERAL.—Any acuity-based pa-
tient classification system adopted by a hospital 
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under this section shall be transparent in all re-
spects, including disclosure of detailed docu-
mentation of the methodology used to predict 
nursing staffing, identifying each factor, as-
sumption, and value used in applying such 
methodology. 
‘‘(B) PUBLIC
AVAILABILITY.—The Sec-
retary shall establish procedures to provide that 
the documentation submitted under subsection 
(e) is available for public inspection in its en-
tirety. 
‘‘(5) REGISTERED
NURSE
PARTICIPATION.—A 
staffing plan of a hospital shall be developed and 
subsequent reevaluations shall be conducted under 
this subsection on the basis of input from direct care 
registered nurses at the hospital or, where such 
nurses are represented through collective bargaining, 
from the applicable recognized or certified collective 
bargaining representative of such nurses. Nothing in 
this title shall be construed to permit conduct pro-
hibited under the National Labor Relations Act or 
under the Federal Labor Relations Act. 
‘‘(d) ACUITY TOOL.— 
‘‘(1) IN
GENERAL.—Not later than 2 years 
after the date of enactment of this title, the Sec-
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retary shall develop a process to establish a national 
acuity tool that provides a transparent method for 
establishing nurse staffing requirements that exceed 
the minimum hospital unit direct care registered 
nurse-to-patient ratios required under subsection 
(b). 
‘‘(2) IMPLEMENTATION.—Each hospital unit 
shall adopt and implement the national acuity tool 
described in paragraph (1), and provide staffing 
based on such tool. Any additional direct care reg-
istered nursing staffing above the hospital unit di-
rect care registered nurse-to-patient ratios described 
in subsection (b) shall be assigned in a manner de-
termined by such national acuity tool. 
‘‘(e) SUBMISSION OF PLAN TO SECRETARY.—A hos-
pital shall submit to the Secretary its staffing plan and 
any annual updates under subsection (c)(3)(B). A feder-
ally operated hospital may submit its staffing plan 
through the department or agency operating the hospital. 
‘‘SEC. 3402. POSTING, RECORDS, AND AUDITS. 
‘‘(a) POSTING REQUIREMENTS.—In each unit, a hos-
pital shall post a uniform notice in a form specified by 
the Secretary in regulation that— 
‘‘(1) explains requirements imposed under sec-
tion 3401; 
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‘‘(2) includes actual direct care registered 
nurse-to-patient ratios during each shift; and 
‘‘(3) is visible, conspicuous, and accessible to 
staff, patients, and the public. 
‘‘(b) RECORDS.— 
‘‘(1) MAINTENANCE OF RECORDS.—Each hos-
pital shall maintain accurate records of actual direct 
care registered nurse-to-patient ratios in each unit 
for each shift for no less than 3 years. Such records 
shall include— 
‘‘(A) the number of patients in each unit; 
‘‘(B) the identity and duty hours of each 
direct care registered nurse assigned to each 
patient in each unit in each shift; and 
‘‘(C) a copy of each notice posted under 
subsection (a). 
‘‘(2) AVAILABILITY
OF
RECORDS.—Each hos-
pital shall make its records maintained under para-
graph (1) available to— 
‘‘(A) the Secretary; 
‘‘(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 
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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. 3403. 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-
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 
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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 3401(b), section 3401(c), and section 3402 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 sections 3401 and 3402. 
‘‘(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. 
‘‘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-
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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 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 3401 through 3403. Such report shall in-
clude recommendations on the need, if any, to adjust reim-
bursement for Medicare payments under subsection (a). 
‘‘SEC. 3405. WHISTLEBLOWER AND PATIENT PROTECTIONS. 
‘‘(a) 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— 
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‘‘(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. 
‘‘(b) 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(4)), including 
discharge, promotion, compensation, or terms, condi-
tions, or privileges of employment, based on the 
nurse’s refusal of a work assignment under sub-
section (a). 
‘‘(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 (a). 
‘‘(c) CAUSE OF ACTION.—Any nurse who has been 
discharged, discriminated against, or retaliated against in 
violation of subsection (b)(1) or against whom a complaint 
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or report has been filed in violation of subsection (b)(2) 
may (without regard to whether a complaint has been filed 
under subsection (d) 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. 
‘‘(d) COMPLAINT TO SECRETARY.—A nurse, patient, 
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 
not suffer any discharge, retaliation, discrimination, 
or other adverse action prohibited by subsection (b) 
or subsection (f). 
‘‘(e) TOLL-FREE TELEPHONE NUMBER.— 
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‘‘(1) IN GENERAL.—The Secretary shall provide 
for the establishment of a toll-free telephone hotline 
to provide information regarding the requirements 
under sections 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. 
‘‘(f) PROTECTION FOR REPORTING.— 
‘‘(1) PROHIBITION
ON
RETALIATION
OR
DIS-
CRIMINATION.—A hospital shall not discriminate or 
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. 
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‘‘(2) GOOD FATH 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. 
‘‘(g) 
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 
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. 
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‘‘(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 
collectively, and engage in concerted activity under 
section 7 of the National Labor Relations Act (29 
U.S.C. 157). 
‘‘(h) NOTICE.—A hospital shall post in an appro-
priate location in each unit a conspicuous notice in a form 
specified 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 
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Secretary against a hospital that violates the provi-
sions of this title; and 
‘‘(3) provides instructions on how to file such a 
complaint. 
‘‘(i) EFFECTIVE DATE.— 
‘‘(1) REFUSAL; RETALIATION; CAUSE
OF
AC-
TION.— 
‘‘(A) 
IN
GENERAL.—Subsections 
(a) 
through (c) 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 (a)(2) shall 
not apply to objections or refusals in any hos-
pital before the requirements of section 3401(a) 
or 3403(a), as applicable, apply to that hos-
pital. 
‘‘(2) PROTECTIONS
FOR
REPORTING.—Sub-
section (f)(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. 
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‘‘(3) NOTICE.—Subsection (h) 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. 
‘‘(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.— 
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‘‘(2) PROCEDURES.—The provisions of section 
1128A of the Social Security Act (other than sub-
sections (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 such section 1128A. 
‘‘(e) PUBLIC NOTICE OF VIOLATIONS.— 
‘‘(1) INTERNET
WEB
SITE.—The Secretary 
shall publish on the Internet Web site of the Depart-
ment of Health and Human Services the names of 
participating hospitals on which civil money pen-
alties have been imposed under this subsection, the 
violation for which such penalty was imposed, and 
such additional information as the Secretary deter-
mines appropriate. 
‘‘(2) CHANGE OF OWNERSHIP.—With respect to 
a participating hospital that had a change of owner-
ship, as determined by the Secretary, penalties im-
posed on the hospital while under previous owner-
ship shall no longer be published by the Secretary of 
such Internet Web site after the 1-year period begin-
ning on the date of change of ownership. 
‘‘(f) OFFSET.—Funds collected by the Secretary 
under this section shall be used to offset the costs of en-
forcing this title. 
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‘‘SEC. 3407. 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 
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 one State to practice as a licensed 
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practical nurse or a licensed vocational nurse and 
who provides bedside care for one or more patients. 
‘‘(3) 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. 
‘‘(4) EMPLOYMENT.—The term ‘employment’ 
includes the provision of services under a contract or 
other arrangement. 
‘‘(5) 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. 
‘‘(6) 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. 
‘‘(7) STAFFING PLAN.—The term ‘staffing plan’ 
means a staffing plan required under section 3401. 
‘‘(8) STATE OF EMERGENCY.—The term ‘state 
of emergency’— 
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‘‘(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 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, 
except in the case where such disclosure is otherwise re-
quired by law, compelled by proper legal process, con-
sented to by the patient, provided in confidence to regu-
latory or accreditation agencies or other government enti-
ties for investigatory purposes, or provided pursuant to 
formal or informal complaints of unlawful or improper 
practices for purposes of achieving corrective and remedial 
action.’’. 
(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 
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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). 
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 (V); 
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