I 
115TH CONGRESS 
2D SESSION 
H. R. 5052 
To amend title XVIII of the Social Security Act to provide for patient 
protection by establishing safe nurse staffing levels at certain Medicare 
providers, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
FEBRUARY 15, 2018 
Mr. JOYCE of Ohio (for himself, Ms. DELBENE, Ms. GABBARD, and Ms. 
BONAMICI) introduced the following bill; which was referred to the Com-
mittee 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 jurisdiction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to provide 
for patient protection by establishing safe nurse staffing 
levels at certain Medicare providers, and for other pur-
poses. 
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 Staffing for 
Nurse and Patient Safety Act of 2018’’. 
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SEC. 2. FINDINGS. 
Congress makes the following findings: 
(1) The overwhelming weight of academic re-
search continues to demonstrate that patient safety, 
prevention of medication errors, failure to rescue sit-
uations, patient deterioration, patient death, and 
nurse burnout are all proportionate to the number of 
nurses staffed in a hospital. Therefore, higher staff-
ing levels by experienced registered nurses are asso-
ciated with lower rates of negative patient outcomes 
and costs. 
(2) Proper nurse staffing decreases the rate of 
patients’ hospital readmissions. Medicare does not 
pay hospitals for patients who are readmitted for the 
same condition within 30 days. In 2013, 17.5 per-
cent of Medicare beneficiaries were readmitted to a 
hospital within 30 days following discharge. These 
readmissions 
cost 
Medicare 
an 
estimated 
$26,000,000,000 per year. The research indicates, 
however, that proper nurse staffing reduces such re-
admissions and pays for itself over the long term. 
(3) The 2015 National Healthcare Retention 
and RN Staffing Report revealed that nurse turn-
over costs the average U.S. hospital nearly 
$5,000,000 every year. Appropriate nurse staffing 
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reduces nurse burnout and turnover, saving hos-
pitals money. 
(4) Proper nurse staffing helps prevent medica-
tion errors and nurse burnout through decreasing 
healthcare worker fatigue. Healthcare worker fatigue 
is a major patient safety hazard. The academic lit-
erature indicates that appropriate staffing policies 
and practices are an effective strategy to reducing 
such fatigue and protecting patients. 
(5) Research shows that optimal nurse staffing 
and skill mix improves patient satisfaction, and re-
sults in savings to hospitals through reductions in 
negative, adverse patient events. Improved patient 
satisfaction due to appropriate nurse staffing is re-
flected in hospitals’ patient satisfaction survey re-
sults, which are publicly reported, and are a key 
measure for value-based payment programs. 
(6) Research indicates that patients who receive 
care during periods of sub-optimal nurse staffing ex-
perience increased rates of medication errors, in-
creased rates of death, increased rates of failure-to- 
rescue, and worse outcomes. 
(7) As a payor for inpatient and outpatient hos-
pital services furnished to Medicare beneficiaries, the 
Federal Government has a compelling interest in 
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promoting the safety of hospitalized patients by re-
quiring any hospital participating in the Medicare 
program to establish appropriate registered nurse 
staffing levels. 
SEC. 3. ESTABLISHMENT OF SAFE NURSE STAFFING LEV-
ELS 
BY 
MEDICARE 
PARTICIPATING 
HOS-
PITALS. 
(a) REQUIREMENT OF MEDICARE PROVIDER AGREE-
MENT.—Section 1866(a)(1) of the Social Security Act (42 
U.S.C. 1395cc(a)(1)) is amended— 
(1) by striking ‘‘and’’ at the end of subpara-
graph (X); 
(2) by striking the period at the end of sub-
paragraph (Y) and inserting ‘‘, and’’; and 
(3) by inserting after subparagraph (Y) the fol-
lowing new subparagraph: 
‘‘(Z) in the case of a hospital (as defined in sec-
tion 1861(e)), to meet the requirements of section 
1899C.’’. 
(b) REQUIREMENTS.—Title XVIII of the Social Secu-
rity Act (42 U.S.C. 1395 et seq.) is amended by adding 
at the end the following new section: 
‘‘NURSE STAFFING REQUIREMENTS FOR MEDICARE 
PARTICIPATING HOSPITALS 
‘‘SEC. 1899C. (a) IMPLEMENTATION
OF NURSE 
STAFFING PLAN.— 
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‘‘(1) IN GENERAL.—Subject to paragraph (3), 
each participating hospital shall implement a hos-
pital-wide staffing plan for nursing services fur-
nished in the hospital. 
‘‘(2) REQUIREMENT
FOR
DEVELOPMENT
OF 
STAFFING
PLAN
BY
HOSPITAL
NURSE
STAFFING 
COMMITTEE.—The hospital-wide staffing plan for 
nursing services implemented by a hospital pursuant 
to paragraph (1)— 
‘‘(A) shall be developed by the hospital 
nurse staffing committee established under sub-
section (b); and 
‘‘(B) shall require that an appropriate 
number of registered nurses provide direct pa-
tient care in each unit and on each shift of the 
hospital to ensure staffing levels that— 
‘‘(i) address the unique characteristics 
of the patients and hospital units; and 
‘‘(ii) result in the delivery of safe, 
quality patient care, consistent with the re-
quirements under subsection (c). 
‘‘(b) HOSPITAL NURSE STAFFING COMMITTEE.— 
‘‘(1) 
ESTABLISHMENT.—Each 
participating 
hospital shall establish a hospital nurse staffing 
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committee (in this section referred to as the ‘Com-
mittee’). 
‘‘(2) COMPOSITION.—A Committee established 
pursuant to this subsection shall be composed of 
members as follows: 
‘‘(A) MINIMUM 55 PERCENT NURSE PAR-
TICIPATION.—Not less than 55 percent of the 
members of the Committee shall be registered 
nurses who provide direct patient care but who 
are neither hospital nurse managers nor part of 
the hospital administration staff. 
‘‘(B) INCLUSION
OF
HOSPITAL
NURSE 
MANAGERS.—The 
Committee 
shall 
include 
members who are hospital nurse managers. 
‘‘(C) INCLUSION OF NURSES FROM SPE-
CIALTY
UNITS.—The members of the Com-
mittee shall include at least 1 registered nurse 
who provides direct care from each nurse spe-
cialty or unit of the hospital (each such spe-
cialty or unit as determined by the hospital). 
‘‘(D) OTHER HOSPITAL PERSONNEL.—The 
Committee shall include such other personnel of 
the hospital as the hospital determines to be ap-
propriate. 
‘‘(3) DUTIES.— 
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‘‘(ii) carry out such additional duties 
as the Committee determines to be appro-
priate. 
‘‘(c) STAFFING PLAN REQUIREMENTS.— 
‘‘(1) PLAN REQUIREMENTS.—Subject to para-
graph (2), a hospital-wide staffing plan for nursing 
services developed and implemented under this sec-
tion shall— 
‘‘(A) be based upon input from the reg-
istered nurse staff of the hospital who provide 
direct patient care or their exclusive representa-
tives, as well as the chief nurse executive; 
‘‘(B) be based upon the number of patients 
and the level and variability of intensity of care 
to be provided to those patients, with appro-
priate consideration given to admissions, dis-
charges, and transfers during each shift; 
‘‘(C) take into account contextual issues 
affecting nurse staffing and the delivery of care, 
including architecture and geography of the en-
vironment and available technology; 
‘‘(D) take into account the level of edu-
cation, training, and experience of those reg-
istered nurses providing direct patient care; 
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‘‘(E) take into account the staffing levels 
and services provided by other health care per-
sonnel associated with nursing care, such as 
certified nurse assistants, licensed vocational 
nurses, licensed psychiatric technicians, nursing 
assistants, aides, and orderlies; 
‘‘(F) take into account staffing levels rec-
ommended by specialty nursing organizations; 
‘‘(G) establish upwardly adjustable min-
imum ratios of direct care registered nurses to 
patients for each unit and for each shift of the 
hospital, based upon an assessment by reg-
istered nurses of the level and variability of in-
tensity of care required by patients under exist-
ing conditions; 
‘‘(H) take into account unit and facility 
level staffing, quality and patient outcome data, 
and national comparisons, as available; 
‘‘(I) ensure that a registered nurse shall 
not be assigned to work in a particular unit of 
the hospital without first having established the 
ability to provide professional care in such unit; 
and 
‘‘(J) provide for exemptions from some or 
all requirements of the hospital-wide staffing 
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plan for nursing services during a declared 
state of emergency (as defined in subsection 
(l)(1)) if the hospital is requested or expected 
to provide an exceptional level of emergency or 
other medical services. 
‘‘(2) LIMITATION.—A hospital-wide staffing 
plan for nursing services developed and implemented 
under this section— 
‘‘(A) shall not preempt any registered- 
nurse staffing levels established under State law 
or regulation; and 
‘‘(B) may not utilize any minimum number 
of registered nurses established under para-
graph (1)(G) as an upper limit on the nurse 
staffing of the hospital to which such minimum 
number applies. 
‘‘(d) REPORTING AND RELEASE TO PUBLIC OF CER-
TAIN STAFFING INFORMATION.— 
‘‘(1) REQUIREMENTS
FOR
HOSPITALS.—Each 
participating hospital shall— 
‘‘(A) post daily for each shift, in a clearly 
visible place, a document that specifies in a uni-
form manner (as prescribed by the Secretary) 
the current number of licensed and unlicensed 
nursing staff directly responsible for patient 
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care in each unit of the hospital, identifying 
specifically the number of registered nurses; 
‘‘(B) upon request, make available to the 
public— 
‘‘(i) the nursing staff information de-
scribed in subparagraph (A); 
‘‘(ii) a detailed written description of 
the hospital-wide staffing plan imple-
mented by the hospital pursuant to sub-
section (a); and 
‘‘(iii) not later than 90 days after the 
date on which an evaluation is carried out 
by 
the 
Committee 
under 
subsection 
(b)(3)(B)(ii), a copy of such evaluation; 
and 
‘‘(C) not less frequently than quarterly, 
submit to the Secretary in a uniform manner 
(as prescribed by the Secretary) the nursing 
staff information described in subparagraph (A) 
through electronic data submission. 
‘‘(2) SECRETARIAL
RESPONSIBILITIES.—The 
Secretary shall— 
‘‘(A) make the information submitted pur-
suant to paragraph (1)(C) publicly available in 
a comprehensible format (as described in sub-
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section (e)(2)(D)(ii)), including by publication 
on the Hospital Compare Internet Web 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 the participating hospital 
is in compliance with the conditions of its 
agreement with the Secretary under section 
1866, including under subsection (a)(1)(Y) of 
such section. 
‘‘(e) RECORDKEEPING; COLLECTION AND REPORT-
ING OF QUALITY DATA; EVALUATION.— 
‘‘(1) 
RECORDKEEPING.—Each 
participating 
hospital shall maintain for a period of at least 3 
years (or, if longer, until the conclusion of any pend-
ing enforcement activities) such records as the Sec-
retary deems necessary to determine whether the 
hospital has implemented a hospital-wide staffing 
plan for nursing services pursuant to subsection (a). 
‘‘(2) COLLECTION AND REPORTING OF QUALITY 
DATA ON NURSING SERVICES.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
require the collection, aggregation, mainte-
nance, and reporting of quality data relating to 
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nursing services furnished by each participating 
hospital. 
‘‘(B) USE OF ENDORSED MEASURES.—In 
carrying out this paragraph, the Secretary shall 
use only quality measures for nursing-sensitive 
care that are endorsed by the consensus-based 
entity with a contract under section 1890(a). 
‘‘(C) USE OF QUALIFIED THIRD-PARTY EN-
TITIES FOR COLLECTION AND SUBMISSION OF 
DATA.— 
‘‘(i) IN
GENERAL.—A participating 
hospital may enter into agreements with 
third-party entities that have demonstrated 
expertise in the collection and submission 
of quality data on nursing services to col-
lect, aggregate, maintain, and report the 
quality data of the hospital pursuant to 
subparagraph (A). 
‘‘(ii) 
CONSTRUCTION.—Nothing 
in 
clause (i) shall be construed to excuse or 
exempt a participating hospital that has 
entered into an agreement described in 
such clause from compliance with require-
ments for quality data collection, aggrega-
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tion, maintenance, and reporting imposed 
under this paragraph. 
‘‘(D) REPORTING OF QUALITY DATA.— 
‘‘(i) PUBLICATION ON HOSPITAL COM-
PARE
WEB
SITE.—Subject to the suc-
ceeding provisions of this subparagraph, 
the Secretary shall make the data sub-
mitted pursuant to subparagraph (A) pub-
licly available, including by publication on 
the Hospital Compare Internet Web site of 
the Department of Health and Human 
Services. 
‘‘(ii) COMPREHENSIBLE
FORMAT.— 
Data made available to the public under 
clause (i) shall be presented in a clearly 
understandable format that permits con-
sumers of hospital services to make mean-
ingful comparisons among hospitals, in-
cluding 
concise 
explanations 
in 
plain 
English of how to interpret the data, of the 
difference in types of nursing staff, of the 
relationship between nurse staffing levels 
and quality of care, and of how nurse 
staffing may vary based on patient case 
mix. 
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‘‘(iii) OPPORTUNITY TO CORRECT ER-
RORS.—The Secretary shall establish a 
process under which participating hospitals 
may review data submitted to the Sec-
retary pursuant to subparagraph (A) to 
correct errors, if any, contained in that 
data submission before making the data 
available to the public under clause (i). 
‘‘(3) EVALUATION
OF
DATA.—The Secretary 
shall provide for the analysis of quality data col-
lected from participating hospitals under paragraph 
(2) in order to evaluate the effect of hospital-wide 
staffing plans for nursing services implemented pur-
suant to subsection (a) on— 
‘‘(A) patient outcomes that are nursing 
sensitive (such as pressure ulcers, fall occur-
rence, falls resulting in injury, length of stay, 
and central line catheter infections); and 
‘‘(B) nursing workforce safety and reten-
tion (including work-related injury, staff skill 
mix, nursing care hours per patient day, va-
cancy and voluntary turnover rates, overtime 
rates, use of temporary agency personnel, and 
nurse satisfaction). 
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‘‘(f) REFUSAL OF ASSIGNMENT.—A nurse may refuse 
to accept an assignment as a nurse in a participating hos-
pital, or in a unit of a participating hospital, if— 
‘‘(1) the assignment is in violation of the hos-
pital-wide staffing plan for nursing services imple-
mented pursuant to subsection (a); 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. 
‘‘(g) ENFORCEMENT.— 
‘‘(1) RESPONSIBILITY.—The Secretary shall en-
force the requirements and prohibitions of this sec-
tion in accordance with the succeeding provisions of 
this subsection. 
‘‘(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 of or a prohibition under this section; and 
‘‘(B) such complaints are investigated by 
the Secretary. 
‘‘(3) REMEDIES.—Except as provided in para-
graph (5), if the Secretary determines that a partici-
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pating hospital has violated a requirement of this 
section, the Secretary— 
‘‘(A) shall require the hospital 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 
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provisions apply to a penalty or proceeding 
under section 1128A. 
‘‘(C) PUBLIC NOTICE OF VIOLATIONS.— 
‘‘(i) INTERNET WEB SITE.—The Sec-
retary shall publish on an appropriate 
Internet Web site of the Department of 
Health and Human Services the names of 
participating hospitals on which civil 
money penalties have been imposed under 
this section, the violation for which the 
penalty was imposed, and such additional 
information as the Secretary determines 
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 Web site after the 
1-year period beginning on the date of the 
change in ownership. 
‘‘(5) PENALTY FOR FAILURE TO COLLECT AND 
REPORT QUALITY DATA ON NURSING SERVICES.— 
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‘‘(A) IN GENERAL.—In the case of a par-
ticipating hospital that fails to comply with re-
quirements under subsection (e)(2) to collect, 
aggregate, maintain, and report quality data re-
lating to nursing services furnished by the hos-
pital, instead of the remedies described in para-
graph (3), the provisions of subparagraph (B) 
shall apply with respect to each such failure of 
the participating hospital. 
‘‘(B) PENALTY.—In the case of a failure 
by a participating hospital to comply with the 
requirements under subsection (e)(2) for a year, 
each such failure shall be deemed to be a failure 
to 
submit 
data 
required 
under 
section 
1833(t)(17)(A), 
section 
1886(b)(3)(B)(viii), 
section 
1886(j)(7)(A), 
or 
section 
1886(m)(5)(A), as the case may be, with re-
spect to the participating hospital involved for 
that year. 
‘‘(h) WHISTLEBLOWER 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-
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sented a grievance or complaint, or has initiated or 
cooperated in any investigation or proceeding of any 
kind, relating to— 
‘‘(A) the hospital-wide staffing plan for 
nursing services developed and implemented 
under this section; or 
‘‘(B) any right, other requirement or pro-
hibition under this section, including a refusal 
to accept an assignment described in subsection 
(f). 
‘‘(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 
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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 discrimination or retaliation; and 
‘‘(B) the term ‘adverse employment action’ 
includes— 
‘‘(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. 
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‘‘(i) RELATIONSHIP TO STATE LAWS.—Nothing in 
this section shall be construed as exempting or relieving 
any person from any liability, duty, penalty, or punish-
ment provided by the law of any State or political subdivi-
sion of a State, other than any such law which purports 
to require or permit any action prohibited under this title. 
‘‘(j) RELATIONSHIP
TO
CONDUCT
PROHIBITED 
UNDER
THE NATIONAL LABOR RELATIONS ACT
OR 
OTHER COLLECTIVE BARGAINING LAWS.—Nothing in 
this section shall be construed as— 
‘‘(1) permitting conduct prohibited under the 
National Labor Relations Act or under any other 
Federal, State, or local collective bargaining law; or 
‘‘(2) preempting, limiting, or modifying a collec-
tive bargaining agreement entered into by a partici-
pating hospital. 
‘‘(k) REGULATIONS.— 
‘‘(1) IN GENERAL.—The Secretary shall pro-
mulgate such regulations as are appropriate and 
necessary to implement this section. 
‘‘(2) IMPLEMENTATION.— 
‘‘(A) IN GENERAL.—Except as provided in 
subparagraph (B), as soon as practicable but 
not later than 2 years after the date of the en-
actment of this section, a participating hospital 
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shall have implemented a hospital-wide staffing 
plan for nursing services under this section. 
‘‘(B) SPECIAL
RULE
FOR
RURAL
HOS-
PITALS.—In the case of a participating hospital 
located in a rural area (as defined in section 
1886(d)(2)(D)), such participating hospital 
shall have implemented a hospital-wide staffing 
plan for nursing services under this section as 
soon as practicable but not later than 4 years 
after the date of the enactment of this section. 
‘‘(l) DEFINITIONS.—In this section: 
‘‘(1) DECLARED STATE OF EMERGENCY.—The 
term ‘declared state of emergency’ means an offi-
cially 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 declare that the State, county, 
municipality, or locality is in a state of emergency, 
but does not include a state of emergency that re-
sults from a labor dispute in the health care indus-
try or consistent understaffing. 
‘‘(2) PARTICIPATING
HOSPITAL.—The term 
‘participating hospital’ means a hospital (as defined 
in section 1861(e)) that has entered into a provider 
agreement under section 1866. 
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‘‘(3) PERSON.—The term ‘person’ means one or 
more individuals, associations, corporations, unincor-
porated organizations, or labor unions. 
‘‘(4) REGISTERED
NURSE.—The term ‘reg-
istered nurse’ means an individual who has been 
granted a license to practice as a registered nurse in 
at least one State. 
‘‘(5) SHIFT.—The term ‘shift’ means a sched-
uled set of hours or duty period to be worked at a 
participating hospital. 
‘‘(6) UNIT.—The term ‘unit’ means, with re-
spect to a hospital, an organizational department or 
separate geographic area of a hospital, including a 
burn unit, a labor and delivery room, a post-anes-
thesia service area, an emergency department, an 
operating room, a pediatric unit, a stepdown or in-
termediate care unit, a specialty care unit, a telem-
etry unit, a general medical care unit, a subacute 
care unit, and a transitional inpatient care unit.’’. 
Æ 
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