I 
108TH CONGRESS 
2D SESSION 
H. R. 4316
To amend the Public Health Service Act to establish direct care registered 
nurse-to-patient staffing ratio requirements in hospitals, and for other 
purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 6, 2004
Ms. SCHAKOWSKY (for herself, Mr. ANDREWS, Mr. CONYERS, Ms. DELAURO, 
Mr. DEUTSCH, Mr. FILNER, Mr. FROST, Mr. HOEFFEL, Mr. HOLDEN, 
Ms. EDDIE BERNICE JOHNSON of Texas, Mrs. MCCARTHY of New York, 
Mr. MEEK of Florida, Mr. NADLER, Ms. NORTON, Ms. ROYBAL-ALLARD, 
Ms. LINDA T. SA´NCHEZ of California, and Mr. VISCLOSKY) 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 jurisdiction of the com-
mittee concerned 
A BILL 
To amend the Public Health Service Act to establish direct 
care registered nurse-to-patient staffing ratio require-
ments in 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; FINDINGS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Nurse Staffing Standards for Patient Safety and Quality 
Care Act of 2004’’. 
(b) FINDINGS.—Congress finds the following: 
(1) The Federal Government has a substantial 
interest in promoting quality care and improving the 
delivery of health care services to patients in health 
care facilities in the United States. 
(2) Recent changes in health care delivery sys-
tems that have resulted in higher acuity levels 
among patients in health care facilities increase the 
need for improved quality measures in order to pro-
tect patient care and reduce the incidence of medical 
errors. 
(3) Inadequate and poorly monitored registered 
nurse staffing practices that result in too few reg-
istered nurses providing direct care jeopardize the 
delivery of quality health care services. 
(4) Numerous studies have shown that patient 
outcomes are directly correlated to direct care reg-
istered nurse staffing levels, including a 2002 Joint 
Commission on Accreditation of Healthcare Organi-
zations report that concluded that the lack of direct 
care registered nurses contributed to nearly a quar-
ter of the unanticipated problems that result in in-
jury or death to hospital patients. 
(5) Requirements for direct care registered 
nurse staffing ratios will help address the registered 
nurse shortage in the United States by aiding in re-
cruitment of new registered nurses and improving 
retention of registered nurses who are considering 
leaving direct patient care because of demands cre-
ated by inadequate staffing. 
(6) Establishing adequate minimum direct care 
registered nurse-to-patient ratios that take into ac-
count patient acuity measures will improve the deliv-
ery of quality health care services and guarantee pa-
tient safety. 
(7) Establishing safe staffing standards for di-
rect care registered nurses is a critical component of 
assuring that there is adequate hospital staffing at 
all levels to improve the delivery of quality care and 
protect patient safety. 
SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE 
STAFFING REQUIREMENT. 
(a) MINIMUM DIRECT CARE REGISTERED NURSE 
STAFFING REQUIREMENT.—The Public Health Service 
Act (42 U.S.C. 201 et seq.) is amended by adding at the 
end the following new title:
‘‘TITLE XXIX—MINIMUM DIRECT 
CARE 
REGISTERED 
NURSE 
STAFFING REQUIREMENT 
‘‘SEC. 2901. MINIMUM NURSE STAFFING REQUIREMENT. 
‘‘(a) STAFFING PLAN.—
‘‘(1) IN GENERAL.—A hospital shall implement 
a staffing plan that—
‘‘(A) provides adequate, appropriate, and 
quality delivery of health care services and pro-
tects patient safety; and 
‘‘(B) is consistent with the requirements of 
this title. 
‘‘(2) EFFECTIVE DATES.—
‘‘(A) 
IMPLEMENTATION
OF
STAFFING 
PLAN.—Subject to subparagraph (B), the re-
quirements under paragraph (1) shall take ef-
fect not later than 1 year after the date of the 
enactment of this title. 
‘‘(B) APPLICATION
OF
MINIMUM
DIRECT 
CARE
REGISTERED
NURSE-TO-PATIENT
RA-
TIOS.—The requirements under subsection (b) 
shall take effect as soon as practicable, as de-
termined 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
‘‘(F) 6 patients in postpartum (3 couplets) 
units and well-baby nursery units. 
‘‘(2) 
SIMILAR
UNITS
WITH
DIFFERENT 
NAMES.—The Secretary may apply minimum direct 
care registered nurse-to-patient ratios established in 
paragraph (1) to a type of hospital unit not referred 
to in such paragraph if such other unit performs a 
function similar to the function performed by the 
unit referred to in such paragraph. 
‘‘(3) 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 
‘‘(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.
‘‘(4) RELATIONSHIP
TO
STATE-IMPOSED
RA-
TIOS.—
‘‘(A) NO PREEMPTION OF CERTAIN STATE-
IMPOSED RATIOS.—Nothing in this title shall 
preempt State standards that the Secretary de-
termines to be at least equivalent to Federal re-
quirements for a staffing plan established under 
this title. Minimum direct care registered nurse-
to-patient ratios established under this sub-
section shall not preempt State requirements 
that the Secretary determines are at least 
equivalent to Federal requirements for a staff-
ing plan established under this title. 
‘‘(B) SATISFACTION OF CERTAIN FEDERAL 
REQUIREMENTS WITH CERTAIN STATE-IMPOSED 
NURSE-TO-PATIENT
RATIOS.—States that, at 
least 2 years prior to the date of the enactment 
of this title, have enacted minimum direct care 
nurse-to-patient ratios that allow the use of li-
censed practical nurses to meet State-imposed 
minimum direct care nurse-to-patient ratios 
may continue to make such allowance, and such 
allowance shall be considered to satisfy require-
ments imposed under this subsection, so long as
the particular licensed practical nurse is em-
ployed in the same or a comparable position. 
‘‘(5) EXEMPTION IN EMERGENCIES.—
‘‘(A) IN GENERAL.—The requirements es-
tablished under this subsection shall not apply 
during a declared state of emergency if a hos-
pital is requested or expected to provide an ex-
ceptional level of emergency or other medical 
services. 
‘‘(B) EMERGENCY
DEFINED.—For pur-
poses of subparagraph (A), the term ‘declared 
state of emergency’ means a state of emergency 
that has been declared by the Federal Govern-
ment 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 such 
term does not include a state of emergency that 
results from a labor dispute in the health care 
industry or consistent understaffing. 
‘‘(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 
2906(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 other health care personnel in meeting direct 
patient care needs not required by a direct care 
registered nurse. 
‘‘(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) 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) 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. 2902. 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 2901; 
‘‘(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 
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. 2903. 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 
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 2901(b), section 2901(c), and section 2902 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 section 2901. 
‘‘(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)(B) of the Social Security Act (42 U.S.C. 
1395ww(d)(2)(B)), not later than 4 years after the date 
of the enactment of this title. 
‘‘SEC. 2904. 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-
quirements imposed under sections 2901 through 2903. 
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 2901 through 
2903. 
‘‘(c) MEDPAC REPORT.—Not later than 2 years 
after the date of the enactment of this title, the Medicare
Payment Advisory Commission (established under section 
1805 of the Social Security Act (42 U.S.C. 1395b-6)) shall 
submit to Congress and the Secretary a report estimating 
total costs and savings attributable to compliance with re-
quirements imposed under sections 2901 through 2903. 
Such report shall include recommendations on the need, 
if any, to adjust reimbursement for Medicare payments 
under subsection (a). 
‘‘SEC. 2905. PROTECTION OF NURSES AND OTHER INDIVID-
UALS. 
‘‘(a) REFUSAL
OF
ASSIGNMENT.—A nurse may 
refuse to accept an assignment as a nurse in a hospital 
if—
‘‘(1) the assignment would violate section 2901 
or 2903; 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 REFUSAL OF ASSIGNMENT 
BARRED.—
‘‘(1) NO DISCHARGE, DISCRIMINATION, OR RE-
TALIATION.—No hospital shall discharge, discrimi-
nate, or retaliate in any manner with respect to any 
aspect of employment (as defined in section
2906(5)), including discharge, promotion, compensa-
tion, or terms, conditions, or privileges of employ-
ment against a nurse based on the nurse’s refusal of 
a work assignment under subsection (a). 
‘‘(2) NO FILING OF COMPLAINT.—No hospital 
shall file a complaint or a report against a nurse 
with the appropriate State professional disciplinary 
agency because of the nurse’s refusal of a work as-
signment under subsection (a). 
‘‘(c) CAUSE OF ACTION.—Any nurse who has been 
discharged, discriminated, or retaliated against in viola-
tion of subsection (b)(1) or against whom a complaint has 
been filed in violation of subsection (b)(2) may 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 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 retaliation under subsection (b) or 
under subsection (e). 
‘‘(e) PROTECTION FOR REPORTING.—
‘‘(1) RETALIATION BARRED.—A hospital shall 
not discriminate or retaliate in any manner with re-
spect to any aspect of employment, including hiring, 
discharge, promotion, compensation, or terms, condi-
tions, or privileges of employment against any indi-
vidual who in good faith, individually or in conjunc-
tion with another person or persons—
‘‘(A) reports a violation or a suspected vio-
lation of this title to the Secretary, a public reg-
ulatory agency, a private accreditation body, or 
the management personnel of the hospital; 
‘‘(B) initiates, cooperates, or otherwise 
participates in an investigation or proceeding 
brought by the Secretary, a public regulatory
agency, or a private accreditation body con-
cerning matters covered by this title; or 
‘‘(C) informs or discusses with other indi-
viduals or with representatives of hospital em-
ployees a violation or suspected violation of this 
title. 
‘‘(2) GOOD FAITH 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. 
‘‘(f) NOTICE.—A hospital shall post in an appropriate 
location in each unit a conspicuous notice in a form speci-
fied by the Secretary that—
‘‘(1) explains the rights of nurses and other in-
dividuals under this section; 
‘‘(2) includes a statement that a nurse or other 
individual may file a complaint with the Secretary 
against a hospital that violates the provisions of this 
title; and 
‘‘(3) provides instructions on how to file a com-
plaint under paragraph (2).
‘‘(g) EFFECTIVE DATES.—
‘‘(1) REFUSAL; RETALIATION; CAUSE
OF
AC-
TION.—
‘‘(A) 
IN
GENERAL.—Subsections 
(a) 
through (c) shall apply to refusals occurring on 
or after the effective date of the provision to 
which the refusal relates. 
‘‘(B) EXCEPTION.—Subsection (a)(2) shall 
not apply to refusals in any hospital before the 
requirements of section 2901(a) apply to that 
hospital. 
‘‘(2) PROTECTIONS
FOR
REPORTING.—Sub-
section (e) shall apply to actions described in sub-
paragraphs (A) and (C) of subsection (e)(1) occur-
ring on or after the effective date of the provision 
to which the violation relates. Subsection (e) shall 
apply to initiation, cooperation, or participation in 
an investigation or proceeding on or after the date 
of the enactment of this title. 
‘‘(3) NOTICE.—Subsection (f) shall take effect 
18 months after the date of the enactment of this 
title. 
‘‘SEC. 2906. 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 1 State to practice as a licensed
practical nurse or a licensed vocational nurse and 
who provides bedside care for 1 or more patients. 
‘‘(3) 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. 
‘‘(4) DIRECT CARE REGISTERED NURSE.—The 
term ‘direct care registered nurse’ means an indi-
vidual who has been granted a license by at least 1 
State to practice as a registered nurse and who pro-
vides bedside care for 1 or more patients. 
‘‘(5) EMPLOYMENT.—The term ‘employment’ 
includes the provision of services under a contract or 
other arrangement. 
‘‘(6) HOSPITAL.—The term ‘hospital’ has the 
meaning given that term in section 1861(e) of the 
Social Security Act (42 U.S.C. 1395x(e)), and in-
cludes a hospital that is operated by the Department 
of Veterans Affairs, the Department of Defense, the 
Indian Health Services Program, or any other de-
partment or agency of the United States. 
‘‘(7) STAFFING PLAN.—The term ‘staffing plan’ 
means a staffing plan required under section 2901.’’. 
(b) RECOMMENDATIONS
TO CONGRESS.—No later 
than 1 year after the date of the enactment of this Act,
the Secretary of Health and Human Services shall submit 
to Congress a report containing recommendations for en-
suring that sufficient numbers of nurses are available to 
meet the requirements imposed by title XXIX of the Pub-
lic Health Service Act, as added by subsection (a). 
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)), as amended 
by the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (Public Law 108–173), 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) the fol-
lowing: 
‘‘(W) in the case of a hospital, to comply 
with the provisions of title XXIX of the Public 
Health Service Act.’’. 
(b) MEDICAID PROGRAM.—The first sentence of sec-
tion 1902(a) of the Social Security Act (42 U.S.C. 
1396(a)) is amended—
(1) by striking ‘‘and’’ at the end of paragraph 
(66); 
(2) by striking the period at the end of para-
graph (67) and inserting ‘‘; and’’; and 
(3) by inserting after paragraph (67) the fol-
lowing new paragraph: 
‘‘(68) provide that any hospital receiving pay-
ments under such plan must comply with the provi-
sions of title XXIX of the Public Health Service 
Act.’’. 
(c) HEALTH BENEFITS PROGRAM OF THE DEPART-
MENT OF VETERANS AFFAIRS.—Section 8110(a) of title 
38, United States Code, is amended by adding at the end 
the following new paragraph: 
‘‘(7) In the case of a Department medical facility that 
is a hospital, the hospital shall comply with the provisions 
of title XXIX of the Public Health Service Act.’’. 
(d) HEALTH BENEFITS PROGRAM OF THE DEPART-
MENT OF DEFENSE.—
(1) IN
GENERAL.—Chapter 55 of title 10, 
United States Code, is amended by adding at the 
end the following new section: