(1) Research shows that patient safety in hos-
pitals is directly proportionate to the number of reg-
istered nurses working in the hospital. Higher staff-
ing levels by experienced registered nurses are re-
lated to lower rates of negative patient outcomes. 
(2) A 2011 study on nurse staffing and inpa-
tient hospital mortality shows that sub-optimal nurse 
staffing is linked with a greater likelihood of patient 
death in the hospital. A 2012 study of serious pa-
tient events reported to the Joint Commission dem-
onstrates that one of the leading causes of all hos-
pital sentinel events is human factors, including 
staffing and staffing skill mix. 
(3) Health care worker fatigue has been identi-
fied as a major patient safety hazard, and appro-
priate staffing policies and practices are indicated as 
an effective strategy to reduce health care worker fa-
tigue and to protect patients. A national survey of 
registered nurses found that 74 percent experience 
acute or chronic effects of stress and overwork. 
(4) A strategy that ensures optimal nurse staff-
ing and skill mix greatly influences patient satisfac-
tion and results in greater overall savings to hos-
pitals through reductions in adverse patient events. 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
(5) A 2009 study demonstrated that improved 
patient satisfaction due to increased and appropriate 
nurse staffing is reflected on hospital scores on 
HCAHPS, which is a key measure for value-based 
payment programs under the Medicare program and 
used by other payors. 
(6) Registered nurses play a vital role in pre-
venting patient care errors. A 2009 study found that 
sufficient staffing of critical care nurses can prevent 
adverse patient events, which can cost anywhere 
from $2,200,000 to $13,200,000. By contrast, the 
nurse staffing costs in the study time period were 
only $1,360,000. 
(7) Higher nurse staffing also generates cost 
savings to payors, as demonstrated in a 2011 cost- 
benefit analysis that weighed registered nursing per-
sonnel costs against emergency department utiliza-
tion after patient discharge from a hospital. 
(8) A 2012 study of Pennsylvania hospitals 
shows that by reducing nurse burnout, which is at-
tributed in part to poor nurse staffing, those hos-
pitals could prevent an estimated 4,160 infections 
with an associated savings of $41,000,000. That 
study also found that for each additional patient as-
signed to a registered nurse for care, there is an in-
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
cidence of roughly one additional catheter-acquired 
urinary tract infection per 1,000 patients or 1,351 
infections per year, costing those hospitals as much 
as $1,100,000 annually. 
(9) When hospitals employ insufficient numbers 
of nursing staff, registered nurses are being required 
to perform professional services under conditions 
that do not support quality health care or a health-
ful work environment for registered nurses. 
(10) As a payor for inpatient and outpatient 
hospital services furnished to Medicare beneficiaries, 
the Federal Government has a compelling interest in 
promoting the safety of these patients by requiring 
any hospital participating in the Medicare program 
to establish minimum safe staffing levels for reg-
istered nurses. 
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) in subparagraph (V), by striking ‘‘and’’ at 
the end; 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
(2) in subparagraph (W), as added by section 
3005 of the Patient Protection and Affordable Care 
Act (Public Law 111–148)— 
(A) by moving such subparagraph 2 ems to 
the left; and 
(B) by striking the period at the end; 
(3) in subparagraph (W), as added by section 
6406(b) of the Patient Protection and Affordable 
Care Act (Public Law 111–148)— 
(A) by moving such subparagraph 2 ems to 
the left; 
(B) by redesignating such subparagraph as 
subparagraph (X); and 
(C) by striking the period at the end and 
inserting ‘‘, and’’; and 
(4) by inserting after subparagraph (X), as re-
designated by paragraph (3)(B), the following new 
subparagraph: 
‘‘(Y) in the case of a hospital (as defined 
in section 1861(e)), to meet the requirements of 
section 1899B.’’. 
(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: 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
‘‘NURSE STAFFING REQUIREMENTS FOR MEDICARE 
PARTICIPATING HOSPITALS 
‘‘SEC. 1899B. (a) IMPLEMENTATION
OF NURSE 
STAFFING PLAN.— 
‘‘(1) IN GENERAL.—Each participating hospital 
shall implement a hospital-wide staffing plan for 
nursing services furnished 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.— 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
‘‘(1) 
ESTABLISHMENT.—Each 
participating 
hospital shall establish a hospital nurse staffing 
committee (hereinafter in this section referred to as 
the ‘Committee’). 
‘‘(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 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
for appropriate time and manner of relief 
of such registered nurses during routine 
absences; and 
‘‘(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; 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
‘‘(D) take into account the level of edu-
cation, training, and experience of those reg-
istered nurses providing direct patient care; 
‘‘(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 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
ability to provide professional care in such unit; 
and 
‘‘(J) provide for exemptions from some or 
all requirements of the hospital-wide staffing 
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— 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
‘‘(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 
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. 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00012
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
‘‘(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-
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). 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00013
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
‘‘(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 
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 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00014
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
exempt a participating hospital that has 
entered into an agreement described in 
such clause from compliance with require-
ments for quality data collection, aggrega-
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 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00015
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
relationship between nurse staffing levels 
and quality of care, and of how nurse 
staffing may vary based on patient case 
mix. 
‘‘(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-
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00016
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
cancy and voluntary turnover rates, overtime 
rates, use of temporary agency personnel, and 
nurse satisfaction). 
‘‘(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 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00017
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
‘‘(B) such complaints are investigated by 
the Secretary. 
‘‘(3) REMEDIES.—Except as provided in para-
graph (5), if the Secretary determines that a partici-
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). 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00018
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
‘‘(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 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 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00019
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
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.— 
‘‘(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.— 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00020
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
‘‘(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— 
‘‘(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. 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00021
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
‘‘(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 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; 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00022
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
‘‘(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. 
‘‘(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.— 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00023
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
‘‘(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 
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, 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00024
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
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. 
‘‘(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 1 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-
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00025
Fmt 6652
Sfmt 6201
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS
etry unit, a general medical care unit, a subacute 
care unit, and a transitional inpatient care unit.’’. 
Æ 
VerDate Mar 15 2010 
03:54 May 02, 2013
Jkt 029200
PO 00000
Frm 00026
Fmt 6652
Sfmt 6301
E:\BILLS\H1821.IH
H1821
pwalker on DSK7TPTVN1PROD with BILLS