113 HR 1907 IH: Nurse Staffing Standards for Patient Safety and Quality Care Act of 2013
U.S. House of Representatives
2013-05-09
text/xml
EN
Pursuant to Title 17 Section 105 of the United States Code, this file is not subject to copyright protection and is in the public domain.
1.Short title; table of
contents; findings
(a)This Act may be cited as the Nurse Staffing Standards for Patient Safety and Quality
Care Act of 2013
.
(b)The table of content for this Act is as follows:
Sec. 1. Short title; table of contents; findings.
Sec. 2. Minimum direct care registered nurse staffing
requirement.
Sec. 3. Enforcement of requirements through Federal
programs.
Sec. 4. Nurse Workforce Initiative.
(c)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 systems that have resulted in higher acuity levels among
patients in health care facilities increase the need for improved quality
measures in order to protect patient care and reduce the incidence of medical
errors.
(3)Inadequate and
poorly monitored registered nurse staffing practices that result in too few
registered 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
registered nurse staffing levels, including a 2002 Joint Commission on
Accreditation of Healthcare Organizations report that concluded that the lack
of direct care registered nurses contributed to nearly a quarter of the
unanticipated problems that result in injury 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 recruitment of new registered
nurses and improving retention of registered nurses who are considering leaving
direct patient care because of demands created by inadequate staffing.
(6)Establishing
adequate minimum direct care registered nurse-to-patient ratios that take into
account patient acuity measures will improve the delivery of quality health
care services and guarantee patient safety.
(7)Establishing safe
staffing standards for direct 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.
2.Minimum direct
care registered nurse staffing requirement
(a)Minimum Direct
Care Registered Nurse Staffing RequirementsThe Public Health Service Act (42 U.S.C.
201 et seq.) is amended by adding at the end the following new title:
<enum>XXXIV</enum><header>MINIMUM DIRECT
CARE REGISTERED NURSE STAFFING REQUIREMENT</header>
<section id="HC671DE01B31644D98614D47137B971F2"><enum>3401.</enum><header>Minimum nurse
staffing requirement</header>
<subsection id="H17A666D60FB24467BCDAEA94E7D70C44"><enum>(a)</enum><header>Staffing
plan</header>
<paragraph commented="no" id="H8D56A07EE65746079AB7507DBFEB48CD"><enum>(1)</enum><header>In
general</header><text>A hospital shall implement a staffing plan that—</text>
<subparagraph commented="no" id="HB69F1722722F4EFAB67C633E6CC82242"><enum>(A)</enum><text>provides adequate,
appropriate, and quality delivery of health care services and protects patient
safety; and</text>
</subparagraph><subparagraph commented="no" id="H9A6C12D2D3C24350A3447C5D2FAFE453"><enum>(B)</enum><text>is consistent with
the requirements of this title.</text>
</subparagraph></paragraph><paragraph id="H5FA68863BD3346C287D962A78AD68923"><enum>(2)</enum><header>Effective
dates</header>
<subparagraph id="H347AD1E92C1B4CC189D7BE4AC93DA87B"><enum>(A)</enum><header>Implementation
of staffing plan</header><text>Subject to subparagraph (B), the requirements
under paragraph (1) shall take effect not later than 1 year after the date of
the enactment of this title.</text>
</subparagraph><subparagraph id="H1B53C3D2AAB64F46A49F495C86AA4E78"><enum>(B)</enum><header>Application of
minimum direct care registered nurse-to-patient ratios</header><text>The
requirements under subsection (b) shall take effect as soon as practicable, as
determined 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.</text>
</subparagraph></paragraph></subsection><subsection id="H74AACAE5EAFA45528C7C6385A9EC5C9E"><enum>(b)</enum><header>Minimum direct
care registered nurse-to-Patient ratios</header>
<paragraph id="HFFD78E2A32F2487F9169A6E8B2888EC4"><enum>(1)</enum><header>In
general</header><text>Except as provided in paragraph (4) and other provisions
of this section, a hospital’s staffing plan shall provide that, at all times
during each shift within a unit of the hospital, a direct care registered nurse
may be assigned to not more than the following number of patients in that
unit:</text>
<subparagraph id="HCACAA6FD58E2459EA7DE24FF8A5CD17F"><enum>(A)</enum><text>One patient in
trauma emergency units.</text>
</subparagraph><subparagraph id="HFBC6B795F8104A5B8DFE99CFC5D78416"><enum>(B)</enum><text>One patient in
operating room units, provided that a minimum of 1 additional person serves as
a scrub assistant in such unit.</text>
</subparagraph><subparagraph id="H4B07B799485347BABA499394C645E7B5"><enum>(C)</enum><text>Two patients in
critical care units, including neonatal intensive care units, emergency
critical care and intensive care units, labor and delivery units, coronary care
units, acute respiratory care units, postanesthesia units, and burn
units.</text>
</subparagraph><subparagraph id="HF908C9CDBE364B0BAE32B7F50019C3C4"><enum>(D)</enum><text display-inline="yes-display-inline">Three patients in emergency room units,
pediatrics units, stepdown units, telemetry units, antepartum units, and
combined labor, deliver, and postpartum units.</text>
</subparagraph><subparagraph id="H7F47544A12F64219AEBBCD4B42940DA5"><enum>(E)</enum><text display-inline="yes-display-inline">Four patients in medical-surgical units,
intermediate care nursery units, acute care psychiatric units, and other
specialty care units.</text>
</subparagraph><subparagraph id="H3265DEE662524F85AC2E7550B2F059E7"><enum>(F)</enum><text>Five patients in
rehabilitation units and skilled nursing units.</text>
</subparagraph><subparagraph id="H04F7EC147660432F87D35273654E3C04"><enum>(G)</enum><text>Six patients in
postpartum (3 couplets) units and well-baby nursery units.</text>
</subparagraph></paragraph><paragraph id="H72DC8356951A422EB923D8552E74F8AE"><enum>(2)</enum><header>Similar units
with different names</header><text display-inline="yes-display-inline">The
Secretary may apply minimum direct care registered nurse-to-patient ratios
established in paragraph (1) for a hospital unit referred to in such paragraph
to a type of hospital unit not referred to in such paragraph if such type of
hospital unit provides a level of care to patients whose needs are similar to
the needs of patients cared for in the hospital unit referred to in such
paragraph.</text>
</paragraph><paragraph id="HDF4BDA00D1DF48F1A816542BA3E3E6CC"><enum>(3)</enum><header>Restrictions</header>
<subparagraph id="H44AB400EA3B94978A660D9A1FD58C0F5"><enum>(A)</enum><header>Prohibition
against averaging</header><text>A hospital shall not average the number of
patients and the total number of direct care registered 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.</text>
</subparagraph><subparagraph id="H10258DF13A84445A82B46B2FEE351016"><enum>(B)</enum><header>Prohibition
against imposition of mandatory overtime requirements</header><text>A hospital
shall not impose mandatory overtime requirements to meet the hospital unit
direct care registered nurse-to-patient ratios required under this
subsection.</text>
</subparagraph><subparagraph id="H74154B19EDD0421E9CD71E0E75668D21"><enum>(C)</enum><header>Relief during
routine absences</header><text>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.</text>
</subparagraph></paragraph><paragraph id="H1CFD5312F44A42EF99D530DB5F0ED634"><enum>(4)</enum><header>Adjustment of
ratios</header>
<subparagraph id="H69AC1BBAF517413E81BDF9313BC7936E"><enum>(A)</enum><header>In
general</header><text>If necessary to protect patient safety, the Secretary may
prescribe regulations that—</text>
<clause id="H5A10B714726A4D09B220E62A41044529"><enum>(i)</enum><text>increase minimum
direct care registered nurse-to-patient ratios under this subsection to further
limit the number of patients that may be assigned to each direct care nurse;
or</text>
</clause><clause id="H7D687E387DA04F88942B57BE532AA8D0"><enum>(ii)</enum><text>add minimum
direct care registered nurse-to-patient ratios for units not referred to in
paragraphs (1) and (2).</text>
</clause></subparagraph><subparagraph id="H9E8958CAA0464E9E9434311B851F82DC"><enum>(B)</enum><header>Consultation</header><text>Such
regulations shall be prescribed after consultation with affected hospitals and
registered nurses.</text>
</subparagraph></paragraph><paragraph id="H0A98DDFF0689459F9D1A0CFB82FAE019"><enum>(5)</enum><header>Relationship to
state-imposed ratios</header><text display-inline="yes-display-inline">Nothing
in this title shall preempt State standards that the Secretary determines to be
at least equivalent to Federal requirements for a staffing plan established
under this title. Minimum direct care registered nurse-to-patient ratios
established under this subsection shall not preempt State requirements that the
Secretary determines are at least equivalent to Federal requirements for a
staffing plan established under this title.</text>
</paragraph><paragraph id="H5195248FB9CA4AE89A40FFB5FAE28CFE"><enum>(6)</enum><header>Exemption in
emergencies</header><text display-inline="yes-display-inline">The requirements
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 describes situations that constitute a state of emergency for
purposes of the exemption under this paragraph.</text>
</paragraph></subsection><subsection id="H4E59F7B5BF714EC9B22A25CC1B40A9A2"><enum>(c)</enum><header>Development and
reevaluation of staffing plan</header>
<paragraph id="H721CA519B66C40C5969F392EA7E54DF3"><enum>(1)</enum><header>Considerations
in development of plan</header><text>In developing the staffing plan, a
hospital shall provide for direct care registered nurse-to-patient ratios above
the minimum direct care registered nurse-to-patient ratios required under
subsection (b) if appropriate based upon consideration of the following
factors:</text>
<subparagraph id="H45F8599CFC73474DAA41A25BEC8F276A"><enum>(A)</enum><text>The number of
patients and acuity level of patients as determined by the application of an
acuity system (as defined in section 3406(1)), on a shift-by-shift
basis.</text>
</subparagraph><subparagraph id="HBFBD3A6436D546CEA56C789E33EE517B"><enum>(B)</enum><text>The anticipated
admissions, discharges, and transfers of patients during each shift that
impacts direct patient care.</text>
</subparagraph><subparagraph id="H6275F425712343F8B4DC61D3B1CD61F9"><enum>(C)</enum><text>Specialized
experience required of direct care registered nurses on a particular
unit.</text>
</subparagraph><subparagraph id="HC29E3F7C58554422982C831B19EA5E73"><enum>(D)</enum><text>Staffing levels
and services provided by licensed vocational or practical nurses, licensed
psychiatric technicians, certified nurse assistants, or other ancillary staff
in meeting direct patient care needs not required by a direct care registered
nurse.</text>
</subparagraph><subparagraph id="H05DA2DC47D564014BC46B23CD5B22777"><enum>(E)</enum><text>The level of
technology available that affects the delivery of direct patient care.</text>
</subparagraph><subparagraph id="HD73BE8EE76644ED4A6A3C77AD870BFB7"><enum>(F)</enum><text>The level of
familiarity with hospital practices, policies, and procedures by temporary
agency direct care registered nurses used during a shift.</text>
</subparagraph><subparagraph id="H4EE1FDCBCA96432EB83AB88E69CB946B"><enum>(G)</enum><text>Obstacles to
efficiency in the delivery of patient care presented by physical layout.</text>
</subparagraph></paragraph><paragraph id="H57A1A3005C3341219F7E37B48B0FDE54"><enum>(2)</enum><header>Documentation of
staffing</header><text>A hospital shall specify the system used to document
actual staffing in each unit for each shift.</text>
</paragraph><paragraph id="HCE3DE2DE66E842BE976C6ED7B898616A"><enum>(3)</enum><header>Annual
reevaluation of plan and acuity system</header>
<subparagraph id="H1A5282D0C5E6484ABAFFF2AE4C6A7F5E"><enum>(A)</enum><header>In
general</header><text>A hospital shall annually evaluate—</text>
<clause id="HC22311372D584D1183C0CC6121DBF9F1"><enum>(i)</enum><text>its staffing plan
in each unit in relation to actual patient care requirements; and</text>
</clause><clause id="H1E5B4E4A692A4412801ECFCB2808BB66"><enum>(ii)</enum><text>the accuracy of
its acuity system.</text>
</clause></subparagraph><subparagraph id="HFC7A34CDC2EC4627BC3ABCF2B65F56A5"><enum>(B)</enum><header>Update</header><text>A
hospital shall update its staffing plan and acuity system to the extent
appropriate based on such evaluation.</text>
</subparagraph></paragraph><paragraph id="H66FA7ECC23134B9F8097B58A7BCD5329"><enum>(4)</enum><header>Transparency</header>
<subparagraph id="H98A5787CEC52472D90845AA4654A029B"><enum>(A)</enum><header>In
General</header><text>Any acuity-based patient classification system adopted by
a hospital under this section shall be transparent in all respects, including
disclosure of detailed documentation of the methodology used to predict nursing
staffing, identifying each factor, assumption, and value used in applying such
methodology.</text>
</subparagraph><subparagraph id="H810CC9149CBE4B36AA4658C1AE300FB5"><enum>(B)</enum><header>Public
availability</header><text>The Secretary shall establish procedures to provide
that the documentation submitted under subsection (e) is available for public
inspection in its entirety.</text>
</subparagraph></paragraph><paragraph id="HCE46F5DF90D447F09A3591FFD1718898"><enum>(5)</enum><header>Registered nurse
participation</header><text>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 prohibited under the
National Labor Relations Act or under the Federal Labor Relations Act.</text>
</paragraph></subsection><subsection id="H5B1AC2DCA5C745D29B07862B0DD9414C"><enum>(d)</enum><header>Acuity
tool</header>
<paragraph id="H23AB9FA38323478489B11C7EA9576882"><enum>(1)</enum><header>In
general</header><text display-inline="yes-display-inline">Not later than 2
years after the date of enactment of this title, the Secretary 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).</text>
</paragraph><paragraph id="H1FFB76E0C523496EB7FC7E5683BC4271"><enum>(2)</enum><header>Implementation</header><text>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 registered nursing staffing above the hospital unit direct care registered
nurse-to-patient ratios described in subsection (b) shall be assigned in a
manner determined by such national acuity tool.</text>
</paragraph></subsection><subsection id="H87C0451F2F914B93B7D225FBBD010BE8"><enum>(e)</enum><header>Submission of
plan to secretary</header><text>A hospital shall submit to the Secretary its
staffing plan and any annual updates under subsection (c)(3)(B). A federally
operated hospital may submit its staffing plan through the department or agency
operating the hospital.</text>
</subsection></section><section id="H1B76A5BBD84F4DBBA17FFBCAEBC1CFF2"><enum>3402.</enum><header>Posting,
records, and audits</header>
<subsection id="HBF4F6DC1C0A446BF853CBEE1C4841451"><enum>(a)</enum><header>Posting
requirements</header><text>In each unit, a hospital shall post a uniform notice
in a form specified by the Secretary in regulation that—</text>
<paragraph id="H43506FF228C940F9ABA549F8AB0D8966"><enum>(1)</enum><text>explains
requirements imposed under section 3401;</text>
</paragraph><paragraph id="H1A64DD95CCBC438CA398D2E1C664AA80"><enum>(2)</enum><text>includes actual
direct care registered nurse-to-patient ratios during each shift; and</text>
</paragraph><paragraph id="HE8D3059FD040402EBFA05DB80963FAB8"><enum>(3)</enum><text>is visible,
conspicuous, and accessible to staff, patients, and the public.</text>
</paragraph></subsection><subsection id="H5381D1E7C97D4CC4823056D53E5B5AD1"><enum>(b)</enum><header>Records</header>
<paragraph id="H45D129D80F7B49AFB51EF30828172A24"><enum>(1)</enum><header>Maintenance of
records</header><text>Each hospital 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—</text>
<subparagraph id="HBA2F37B2E2174C00BE4DB4C68D9654A5"><enum>(A)</enum><text>the number of
patients in each unit;</text>
</subparagraph><subparagraph id="H8772D5439689470781D910CF7DB47E3F"><enum>(B)</enum><text>the identity and
duty hours of each direct care registered nurse assigned to each patient in
each unit in each shift; and</text>
</subparagraph><subparagraph id="HFCBE8DDF14B9417E8843355E074A47B5"><enum>(C)</enum><text>a copy of each
notice posted under subsection (a).</text>
</subparagraph></paragraph><paragraph id="H863EB30558884FFCA088E3D792694ED1"><enum>(2)</enum><header>Availability of
records</header><text>Each hospital shall make its records maintained under
paragraph (1) available to—</text>
<subparagraph id="HD3DC7D51F04D42F7B0CE23DCDE76A281"><enum>(A)</enum><text>the
Secretary;</text>
</subparagraph><subparagraph id="HC9E2A63DCDB34FB082EBE2CBD5D8E4D1"><enum>(B)</enum><text>registered nurses
and their collective bargaining representatives (if any); and</text>
</subparagraph><subparagraph id="HBCE0F3D6422C46009352C3532881F284"><enum>(C)</enum><text>the public under
regulations established by the Secretary, or in the case of a federally
operated hospital, under <external-xref legal-doc="usc" parsable-cite="usc/5/552">section 552</external-xref> of title 5, United States Code (commonly
known as the <term>Freedom of Information Act</term>).</text>
</subparagraph></paragraph></subsection><subsection id="H34FD7BF9B15E4E88A41A2F1685ADB97F"><enum>(c)</enum><header>Audits</header><text>The
Secretary shall conduct periodic audits to ensure—</text>
<paragraph id="HC0812DB4D7B34CC3A00CAB2124E0B95D"><enum>(1)</enum><text>implementation of
the staffing plan in accordance with this title; and</text>
</paragraph><paragraph id="HEC357E789570437C98AF1E0BC6397616"><enum>(2)</enum><text>accuracy in
records maintained under this section.</text>
</paragraph></subsection></section><section id="H08BFB8CEB9214EB1AA4A4CF1D38F4652"><enum>3403.</enum><header>Minimum direct
care licensed practical nurse staffing requirements</header>
<subsection id="H04B54CE90FFD4C0AB670A7239A60BA1C"><enum>(a)</enum><header>Establishment</header><text>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).</text>
</subsection><subsection id="H164B1D8BF2FB4316ABD37C2574220807"><enum>(b)</enum><header>Study</header><text>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 Research 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 entity or
organization to carry out such study under this paragraph. The Director shall
consult with licensed practical nurses and organizations representing licensed
practical nurses regarding the design and conduct of the study.</text>
</subsection><subsection id="H12E02055CAC849B3910CF1E71E43B7A0"><enum>(c)</enum><header>Application of
registered nurse provisions to licensed practical nurse staffing
requirements</header><text>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 establishment and
application of direct care registered nurse-to-patient ratios under sections
3401 and 3402.</text>
</subsection><subsection id="H1713B222465C42F084587FD2A600284D"><enum>(d)</enum><header>Effective
date</header><text>The requirements of this section shall take effect as soon
as practicable, as determined 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.</text>
</subsection></section><section id="HB4A83F1D10314D4BAE5A35A5EB71AEA1"><enum>3404.</enum><header>Adjustment in
reimbursement</header>
<subsection id="H2198C3CE7B9C46C8B42BD83760BC9846"><enum>(a)</enum><header>Medicare
reimbursement</header><text>The Secretary shall adjust payments made to
hospitals (other than federally operated hospitals) under title XVIII of the
Social Security Act in an amount equal to the net amount of additional costs
incurred in providing services to Medicare beneficiaries that are attributable
to compliance with requirements imposed under sections 3401 through 3403. The
amount of such payment adjustments shall take into account recommendations
contained in the report submitted by the Medicare Payment Advisory Commission
under subsection (c).</text>
</subsection><subsection id="H4DA7BBDF647A49AE8C6F58780EC9BF04"><enum>(b)</enum><header>Authorization of
appropriation for federally operated hospitals</header><text>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.</text>
</subsection><subsection id="HE912B2FDADEA4F6F917D3723916C8F39"><enum>(c)</enum><header>Medpac
report</header><text>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) shall submit to Congress and the Secretary a
report estimating total costs and savings attributable to compliance with
requirements imposed under sections 3401 through 3403. Such report shall
include recommendations on the need, if any, to adjust reimbursement for
Medicare payments under subsection (a).</text>
</subsection></section><section id="H62AAE4C6F7234E1D828360031AED8C62"><enum>3405.</enum><header>Whistleblower
and patient protections</header>
<subsection id="H88140CB6DCBE41D8AEA7DA6D1F3F489E"><enum>(a)</enum><header>Objection to or
refusal of assignment</header><text display-inline="yes-display-inline">A nurse
may object to, or refuse to participate in, any activity, policy, practice,
assignment or task if in good faith—</text>
<paragraph id="H97B936B7BCB641AAAD47AC4ADB74AACF"><enum>(1)</enum><text display-inline="yes-display-inline">the nurse reasonably believes it to be in
violation of section 3401 or 3403; or</text>
</paragraph><paragraph id="H48202BEC7C484EAAB42EBD6CFAAD28DA"><enum>(2)</enum><text>the nurse is not
prepared by education, training, or experience to fulfill the assignment
without compromising the safety of any patient or jeopardizing the license of
the nurse.</text>
</paragraph></subsection><subsection id="HA6119B80EB3B4801889FC9EFBD8B1D21"><enum>(b)</enum><header>Retaliation for
objection to or refusal of assignment barred</header>
<paragraph id="H1AD3AD8A72D34833BEC12ABBBDBB5959"><enum>(1)</enum><header>No discharge,
discrimination, or retaliation</header><text display-inline="yes-display-inline">No hospital shall discharge, retaliate,
discriminate, or otherwise take adverse action in any manner with respect to
any aspect of a nurse’s employment (as defined in section 3407(4)), including
discharge, promotion, compensation, or terms, conditions, or privileges of
employment, based on the nurse’s refusal of a work assignment under subsection
(a).</text>
</paragraph><paragraph id="HEBC8EBC7EE034B0DA9A061195DDEA35D"><enum>(2)</enum><header>No filing of
complaint</header><text>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).</text>
</paragraph></subsection><subsection id="HA581203CBFF64D3AA58279C3E0EAF30B"><enum>(c)</enum><header>Cause of
action</header><text display-inline="yes-display-inline">Any nurse who has been
discharged, discriminated against, or retaliated against in violation of
subsection (b)(1) or against whom a complaint 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:</text>
<paragraph id="H8BD0B30A136E4A188C0B2D8E34B5158E"><enum>(1)</enum><text display-inline="yes-display-inline">Reinstatement.</text>
</paragraph><paragraph id="H95D80E8AE79C473EAA5C83D3BCE865A9"><enum>(2)</enum><text>Reimbursement of
lost wages, compensation, and benefits.</text>
</paragraph><paragraph id="H2F3792E6399548FBA83A1AD4C24D99F1"><enum>(3)</enum><text>Attorneys’
fees.</text>
</paragraph><paragraph id="HA4498E695A304939A0182EE88B49A6D9"><enum>(4)</enum><text>Court
costs.</text>
</paragraph><paragraph id="H54EF83DEBFF940C29BCAE6045EC71905"><enum>(5)</enum><text>Other
damages.</text>
</paragraph></subsection><subsection commented="no" id="H24D597EBFA694D07A7A82A5588BEF20F"><enum>(d)</enum><header>Complaint to
Secretary</header><text display-inline="yes-display-inline">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—</text>
<paragraph commented="no" id="H3E3B4932060144F6B5B94F182EB0175B"><enum>(1)</enum><text display-inline="yes-display-inline">receive and investigate the
complaint;</text>
</paragraph><paragraph commented="no" id="HB4BE98B3CCA14A0482CB18E2A18D53D0"><enum>(2)</enum><text>determine whether
a violation of this title as alleged in the complaint has occurred; and</text>
</paragraph><paragraph commented="no" id="H22CA1B7C89D343F1A827AC729875E5F8"><enum>(3)</enum><text display-inline="yes-display-inline">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).</text>
</paragraph></subsection><subsection id="HE4BFE1D389674264A3510CB4985CED85"><enum>(e)</enum><header>Toll-Free
telephone number</header>
<paragraph id="HCB5B2BFB154D4BD2B304D5B5B4FFD0D5"><enum>(1)</enum><header>In
general</header><text display-inline="yes-display-inline">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 reports of violations of such section.</text>
</paragraph><paragraph id="H79669CC49F7A4ED8A40871A232E3A71A"><enum>(2)</enum><header>Notice to
patients</header><text display-inline="yes-display-inline">A hospital shall
provide each patient admitted to the hospital for inpatient 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.</text>
</paragraph></subsection><subsection id="H37A78D6F86C2421DA2299352F4EAAEC4"><enum>(f)</enum><header>Protection for
reporting</header>
<paragraph id="HBBDAAB98D7944301B66DA8860E1E47DA"><enum>(1)</enum><header>Prohibition on
retaliation or discrimination</header><text display-inline="yes-display-inline">A hospital shall not discriminate or
retaliate in any manner against any patient, employee, or contract employee of
the hospital, or any other individual, on the basis that such individual, in
good faith, individually or in conjunction with another person or persons, has
presented a grievance or complaint, or has initiated or cooperated in any
investigation or proceeding of any governmental entity, regulatory agency, or
private accreditation body, made a civil claim or demand, or filed an action
relating to the care, services, or conditions of the hospital or of any
affiliated or related facilities.</text>
</paragraph><paragraph id="H93633BAFFCB64A87BBAE1EFCC51EE217"><enum>(2)</enum><header>Good fath
defined</header><text display-inline="yes-display-inline">For purposes of this
subsection, an individual shall be deemed to be acting in good faith if the
individual reasonably believes—</text>
<subparagraph id="H666FBF607CE842FC9F4C6172C0EDECF4"><enum>(A)</enum><text display-inline="yes-display-inline">the information reported or disclosed is
true; and</text>
</subparagraph><subparagraph id="H9772F897C2A343B1BC6A7055A90174BA"><enum>(B)</enum><text>a violation of
this title has occurred or may occur.</text>
</subparagraph></paragraph></subsection><subsection id="HB87A519F6F974E729ED0978228553D0A"><enum>(g)</enum><header>Prohibition on
interference with rights</header>
<paragraph id="H03FB77E6227C47A69A7DF4147E8B1160"><enum>(1)</enum><header>Exercise of
rights</header><text display-inline="yes-display-inline">It shall be unlawful
for any hospital to—</text>
<subparagraph id="H4E2F6A101794488DB92F3853378C3FEE"><enum>(A)</enum><text display-inline="yes-display-inline">interfere with, restrain, or deny the
exercise, or attempt to exercise, by any person of any right provided or
protected under this title; or</text>
</subparagraph><subparagraph id="H3455233CD38C4958945A9A649DB58A2F"><enum>(B)</enum><text>coerce or
intimidate any person regarding the exercise or attempt to exercise such
right.</text>
</subparagraph></paragraph><paragraph id="H212CA8CD9E0C4FC78AE94980412D257C"><enum>(2)</enum><header>Opposition to
unlawful policies or practices</header><text display-inline="yes-display-inline">It shall be unlawful for any hospital to
discriminate or retaliate against any person for opposing any hospital policy,
practice, or actions which are alleged to violate, breach, or fail to comply
with any provision of this title.</text>
</paragraph><paragraph commented="no" id="H7C00A1DDE3CF47AD912A317CB558DB78"><enum>(3)</enum><header>Prohibition on
interference with protected communications</header><text display-inline="yes-display-inline">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
direct care nurse regarding, engaging in free speech activities or disclosing
information as provided under this title.</text>
</paragraph><paragraph id="HA43B24D7E5F1418EAF3414C7540B56CB"><enum>(4)</enum><header>Prohibition on
interference with collective action</header><text display-inline="yes-display-inline">A hospital (or an individual representing a
hospital) shall not in any way interfere with the rights of nurses to organize,
bargain collectively, and engage in concerted activity under section 7 of the
National Labor Relations Act (<external-xref legal-doc="usc" parsable-cite="usc/29/157">29 U.S.C. 157</external-xref>).</text>
</paragraph></subsection><subsection id="H4121A427FC7C4EE49171601FC6FC7607"><enum>(h)</enum><header>Notice</header><text display-inline="yes-display-inline">A hospital shall post in an appropriate
location in each unit a conspicuous notice in a form specified by the Secretary
that—</text>
<paragraph id="H098900D2B5B74F58B5D5B4E4EA248B68"><enum>(1)</enum><text display-inline="yes-display-inline">explains the rights of nurses, patients,
and other individuals under this section;</text>
</paragraph><paragraph id="H812B69BC60644C0BB1ED49E994D56B0F"><enum>(2)</enum><text>includes a
statement that a nurse, patient, or other individual may file a complaint with
the Secretary against a hospital that violates the provisions of this title;
and</text>
</paragraph><paragraph id="HBA3F74FD06DB4210B52B7780D774A7D8"><enum>(3)</enum><text>provides
instructions on how to file such a complaint.</text>
</paragraph></subsection><subsection id="HD99A5C40EED646C1892934E29EB8642D"><enum>(i)</enum><header>Effective
date</header>
<paragraph id="H13AFB253557549EEAAFDA0D285F2624B"><enum>(1)</enum><header>Refusal;
retaliation; cause of action</header>
<subparagraph id="HA9381BDA20BE43C695CC942077898C09"><enum>(A)</enum><header>In
general</header><text display-inline="yes-display-inline">Subsections (a)
through (c) shall apply to objections and refusals occurring on or after the
effective date of the provision of this title to which the objection or refusal
relates.</text>
</subparagraph><subparagraph id="H3A4DA13A39AE4F1786FACEB367866EFA"><enum>(B)</enum><header>Exception</header><text display-inline="yes-display-inline">Subsection (a)(2) shall not apply to
objections or refusals in any hospital before the requirements of section
3401(a) or 3403(a), as applicable, apply to that hospital.</text>
</subparagraph></paragraph><paragraph id="HDF2BA1262D674F9992A969A744CB3B1F"><enum>(2)</enum><header>Protections for
reporting</header><text display-inline="yes-display-inline">Subsection (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.</text>
</paragraph><paragraph id="HD3087FF2332241139354ECB99680F8DA"><enum>(3)</enum><header>Notice</header><text display-inline="yes-display-inline">Subsection (h) shall take effect 18 months
after the date of enactment of this title.</text>
</paragraph></subsection></section><section id="HDEDE53775335430898DB995D684694DB"><enum>3406.</enum><header>Enforcement</header>
<subsection id="HD7FFFFCB68CC4E3BA8768CCE6AC0E7DB"><enum>(a)</enum><header>In
general</header><text>The Secretary shall enforce the requirements and
prohibitions of this title in accordance with this section.</text>
</subsection><subsection id="HBC44AF2815EC4545A8D5DEBA694AEFA4"><enum>(b)</enum><header>Procedures for
receiving and investigating complaints</header><text>The Secretary shall
establish procedures under which—</text>
<paragraph id="H1C0BD78D4B7C4647A96FDE5033A5661B"><enum>(1)</enum><text>any person may
file a complaint alleging that a hospital has violated a requirement or a
prohibition of this title; and</text>
</paragraph><paragraph id="H11593C009FC34D27854FA9721916A398"><enum>(2)</enum><text>such complaints
shall be investigated by the Secretary.</text>
</paragraph></subsection><subsection id="H6EEA3DBD430B419BA4348007E9831A49"><enum>(c)</enum><header>Remedies</header><text>If
the Secretary determines that a hospital has violated a requirement of this
title, the Secretary—</text>
<paragraph id="HACC657ADA39146DAA0A5D2C2BCCB62BB"><enum>(1)</enum><text>shall require the
facility to establish a corrective action plan to prevent the recurrence of
such violation; and</text>
</paragraph><paragraph id="H5B0A9B1682074F03B98B1EA529063F5C"><enum>(2)</enum><text>may impose civil
money penalties, as described in subsection (d).</text>
</paragraph></subsection><subsection id="HAFC4DD0C00C344229A803FAB102A5020"><enum>(d)</enum><header>Civil
penalties</header>
<paragraph id="HE89B3ABC1909492CA982EDA3527CE0F7"><enum>(1)</enum><header>In
general</header><text>In addition to any other penalties prescribed by law, the
Secretary may impose civil penalties as follows:</text>
<subparagraph id="H412D22C5A18845869575B72791645EEB"><enum>(A)</enum><header>Hospital
liability</header><text>The Secretary may impose on a hospital found to be in
violation of this title, a civil money penalty of not more than $25,000 for
each knowing violation of a requirement of this title, except that the
Secretary shall impose a civil money penalty of more than $25,000 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
additional penalties being determined in accordance with a schedule or
methodology specified in regulations).</text>
</subparagraph><subparagraph id="HB7410BE1CE02456EAAF56A815048933E"><enum>(B)</enum><header>Individual
liability</header><text>The Secretary may impose on an individual who—</text>
<clause id="H233EDB0097D24ED6AE63D4834401D1E2"><enum>(i)</enum><text>is
employed by a hospital found by the Secretary to have violated a requirement of
this title; and</text>
</clause><clause id="H3C5C108037774FDF80E5B41724891E92"><enum>(ii)</enum><text>willfully
violates this title,</text>
</clause><continuation-text continuation-text-level="subparagraph">a civil
money penalty of not more than $20,000 for each such violation.</continuation-text></subparagraph></paragraph><paragraph id="H05053FAD660A4DA3B7B579FA5D4D282E"><enum>(2)</enum><header>Procedures</header><text>The
provisions of section 1128A of the Social Security Act (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 such
section 1128A.</text>
</paragraph></subsection><subsection id="HF8E6CDCB00514248AE9255F6F5AB718D"><enum>(e)</enum><header>Public notice of
violations</header>
<paragraph id="H7B9501E0D1A94BC08B1B95BBC1DA186C"><enum>(1)</enum><header>Internet Web
site</header><text>The Secretary shall publish on the 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 subsection, the
violation for which such penalty was imposed, and such additional information
as the Secretary determines appropriate.</text>
</paragraph><paragraph id="H68749B02497045A18CAA2A682F6AF9EA"><enum>(2)</enum><header>Change of
ownership</header><text>With respect to a participating hospital that had a
change of ownership, as determined by the Secretary, penalties imposed on the
hospital while under previous ownership shall no longer be published by the
Secretary of such Internet Web site after the 1-year period beginning on the
date of change of ownership.</text>
</paragraph></subsection><subsection id="H3BFBF872D1A843AFA0EAF91D7215E8AE"><enum>(f)</enum><header>Offset</header><text>Funds
collected by the Secretary under this section shall be used to offset the costs
of enforcing this title.</text>
</subsection></section><section id="HB1FB840F78B142FFBCDB72639ED9799E"><enum>3407.</enum><header>Definitions</header><text display-inline="no-display-inline">For purposes of this title:</text>
<paragraph id="HA3852A1E9A3B4FD7AB2940CA81E5FA0C"><enum>(1)</enum><header>Acuity
system</header><text>The term <term>acuity system</term> means an established
measurement tool that—</text>
<subparagraph id="H85916E7242F7496288D9B13BC115179E"><enum>(A)</enum><text>predicts nursing
care requirements for individual patients based on severity of patient 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;</text>
</subparagraph><subparagraph id="HC64B3F77F1234B9381D2D38DD3B39DE0"><enum>(B)</enum><text>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;</text>
</subparagraph><subparagraph id="HF5A18218B0EA4F27BAFB4F7D581BB9C8"><enum>(C)</enum><text>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</text>
</subparagraph><subparagraph id="H3745D1F1973C48C1AF502ACB8886C326"><enum>(D)</enum><text>is stated in terms
that can be readily used and understood by nurses.</text>
</subparagraph></paragraph><paragraph id="HBBB104A140864BA9A455459F0F0C9A25"><enum>(2)</enum><header>Direct care
licensed practical nurse</header><text>The term <term>direct care licensed
practical nurse</term> means an individual who has been granted a license by at
least one State to practice as a licensed practical nurse or a licensed
vocational nurse and who provides bedside care for one or more patients.</text>
</paragraph><paragraph id="H5ACA6038D3DB4AB8BDF74BC97B0F29F0"><enum>(3)</enum><header>Direct care
registered nurse</header><text>The term <term>direct care registered
nurse</term> means an individual 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.</text>
</paragraph><paragraph id="HE0B9AFD8C43C41DEB050A38E769CE18E"><enum>(4)</enum><header>Employment</header><text>The
term <term>employment</term> includes the provision of services under a
contract or other arrangement.</text>
</paragraph><paragraph id="H21CE9F665A474A9AB11122FB1B419B76"><enum>(5)</enum><header>Hospital</header><text>The
term <term>hospital</term> 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.</text>
</paragraph><paragraph id="H91F90B27FEF7436BB43D12FE05967CAF"><enum>(6)</enum><header>Nurse</header><text>The
term <term>nurse</term> means any direct care registered nurse or direct care
licensed practical nurse (as the case may be), regardless of whether or not the
nurse is an employee.</text>
</paragraph><paragraph id="HD52DA684EA9645C39D56FEDA44017881"><enum>(7)</enum><header>Staffing
plan</header><text>The term <term>staffing plan</term> means a staffing plan
required under section 3401.</text>
</paragraph><paragraph id="H8F5962ADA67E42D4AABAA981A46946BE"><enum>(8)</enum><header>State of
emergency</header><text>The term <term>state of emergency</term>—</text>
<subparagraph id="H8C1676E7BA11495FA9E4A6CA16EDDCD1"><enum>(A)</enum><text>means a state of
emergency that is an unpredictable or unavoidable occurrence at an unscheduled
or unpredictable interval, relating to health care delivery and requiring
immediate medical interventions and care; and</text>
</subparagraph><subparagraph id="H4565AAE704C1441E966ED04EF9ECBC3A"><enum>(B)</enum><text>does not include a
state emergency that results from a labor dispute in the health care industry
or consistent understaffing.</text>
</subparagraph></paragraph></section><section commented="no" id="H8F754DB25286484E96E8F3774D9D019C"><enum>3408.</enum><header>Rule of
construction</header><text display-inline="no-display-inline">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
required by law, compelled by proper legal process, consented to by the
patient, provided in confidence to regulatory or accreditation agencies or
other government entities for investigatory purposes, or provided pursuant to
formal or informal complaints of unlawful or improper practices for purposes of
achieving corrective and remedial
action.</text>
</section>.
(b)Recommendations
to CongressNot 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
ensuring that sufficient numbers of nurses are available to meet the
requirements imposed by title XXXIV of the Public Health Service Act, as added
by subsection (a).
(c)
(1)Not later than 2
years after the date of enactment of this Act, the Administrator of the Health
Resources and Services Administration, 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)Not later than 5 years
after the date of enactment of this Act, the Administrator of the Health
Resources and Services Administration, in consultation with the National Health
Care Workforce Commission, shall submit to Congress an update of the report
submitted under paragraph (1).
3.Enforcement of
requirements through Federal programs
(a)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 subparagraph (V);
(2)in the subparagraph (W) added by section
3005(1)(C) of Public Law 111–148—
(A)by striking the period at the end and
inserting a comma;
(B)by moving the
indentation 2 ems to the left; and
(C)by moving such
subparagraph to immediately follow subparagraph (V);
(3)in the subparagraph (W) added by section
6406(b)(3) of Public Law 111–148—
(A)by striking the period at the end and
inserting , and
;
(B)by moving the
indentation 2 ems to the left;
(C)by redesignating
such subaragraph as subparagraph (X); and
(D)by moving such
subparagraph to immediately follow subparagraph (W), as moved under paragraph
(2)(C); and
(4)by inserting after
the subparagraph (X), as redesignated and moved under paragraph (3), the
following:
(Y)in the case of a hospital, to comply
with the provisions of title XXXIV of the Public Health Service
Act.
.
(b)Section 1902(a) of the Social Security Act (42 U.S.C.
1396(a)) is amended—
(1)by striking
and
at the end of paragraph (82)(C);
(2)by striking the
period at the end of paragraph (83) and inserting ; and
;
and
(3)by inserting after
paragraph (83) the following new paragraph:
(84)provide that any hospital that receives a
payment under such plan comply with the provisions of title XXXIV of the Public
Health Service Act (relating to minimum direct care registered nurse staffing
requirements).
.
(c)Health benefits
program of the department of veterans affairsSection 8110(a) of
title 38, United States Code, is amended by adding at the end the following new
paragraphs:
(7)In the case of a Department medical
facility that is a hospital, the hospital shall comply with the provisions of
title XXXIV of the Public Health Service Act.
(8)Nothing either in chapter 74 of this
title or in section 7106 of title 5 shall preclude enforcement of the
provisions of title XXXIV of the Public Health Service Act with respect to a
Department hospital through grievance procedures negotiated in accordance with
chapter 71 of title
5.
.
(d)Health benefits
program of the department of defense
(1)Chapter 55 of title 10, United States Code, is amended by
adding at the end the following new section:
1110c.In the case of a
facility of the uniformed services that is a hospital, the hospital shall
comply with the provisions of title XXXIV of the Public Health Service
Act.
.
(2)The table of sections at the beginning of such chapter
is amended by inserting after the item relating to section 1110b the following
new item:
1110c. Staffing
requirements.
.
(e)Indian health
services programTitle VIII of the Indian Health Care Improvement
Act (25 U.S.C. 1671 et seq.) is amended by adding at the end the following new
section:
833.All hospitals of
the Service shall comply with the provisions of title XXXIV of the Public
Health Service Act (relating to minimum direct care registered nurse staffing
requirements).
.
(f)Federal
labor-Management relations
(1)Section 7106 of title 5, United States Code, is amended
by adding at the end the following:
(c)Nothing in this
section shall preclude enforcement of the provisions of title XXXIV of the
Public Health Service Act through grievance procedures negotiated in accordance
with section
7121.
.
(2)Section 7106(a) of title 5, United States Code, is
amended by striking Subject to subsection (b) of this title,
and
inserting Subject to subsections (b) and (c),
.
4.Nurse Workforce
Initiative
(a)Scholarship and
stipend programSection 846(d) of the Public Health Service Act
(42 U.S.C. 297n(d)) is amended—
(1)in the section
heading, by inserting and
Stipend
after Scholarship
; and
(2)in paragraph (1),
by inserting or stipends
after
scholarships
.
(b)Section 831A(b) of the Public Health Service Act (42
U.S.C. 296p–1(b)) is amended—
(1)by striking
Grants for Career Ladder
Program.—
and inserting Grants for Nurse
Retention.—
;
(2)in paragraph (2),
by striking ; or
and inserting a semicolon;
(3)in paragraph (3),
by striking the period and inserting a semicolon; and
(4)by adding at the
end the following:
(4)to provide
additional support to nurses entering the workforce by implementing nursing
preceptorship projects that establish a period of practical and clinical
experiences and training for nursing students, newly hired nurses, and recent
graduates of a direct care degree programs for registered nurses; or
(5)to implement
mentorship projects that assist new or transitional direct care registered
nurses in adapting to the hospital
setting.
.