I 111th CONGRESS 1st Session H. R. 2273 IN THE HOUSE OF REPRESENTATIVES May 6, 2009 Ms. Schakowsky (for herself, Ms. Eddie Bernice Johnson of Texas, Mr. Stark, Mr. Rangel, Mr. Conyers, Mr. Young of Alaska, Mr. Abercrombie, Mr. McGovern, Mr. Sherman, Ms. DeLauro, Mr. Ellison, and Ms. Baldwin) 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 committee concerned A BILL To amend the Public Health Service Act to establish direct care registered nurse-to-patient staffing ratio requirements in hospitals, and for other purposes.
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 2009. (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 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 requirement
The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by adding at the end the following new title: <enum>XXXI</enum><header>Minimum direct care registered nurse staffing requirement</header> <section id="HC4A9D3A1602A4F1AAEF30FBC23624699"><enum>3101.</enum><header>Minimum nurse staffing requirement</header> <subsection id="H21118D03D82F447899046F90971C52C0"><enum>(a)</enum><header>Staffing plan</header> <paragraph id="HB10BD2A5A61C405E9CD4A54C846F5BFF"><enum>(1)</enum><header>In general</header><text>A hospital shall implement a staffing plan that—</text> <subparagraph id="HD52B235ABDF946D3BBAEFC24D0546699"><enum>(A)</enum><text>provides adequate, appropriate, and quality delivery of health care services and protects patient safety; and</text> </subparagraph><subparagraph id="H17C78165192041DFA228E35E7B71A1A8"><enum>(B)</enum><text>is consistent with the requirements of this title.</text> </subparagraph></paragraph><paragraph id="H52A969F3DD7B44C58232E07D4068106C"><enum>(2)</enum><header>Effective dates</header> <subparagraph id="HB912504D45944F29AEC72051BEAA8A45"><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="H88B01F1BB50B4BEE8EFDD69AC301CE5E"><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 <act-name parsable-cite="SSA">Social Security Act</act-name>), not later than 4 years after the date of the enactment of this title.</text> </subparagraph></paragraph></subsection><subsection id="H9F28075780A345FD80D2B6536BB5A5A3"><enum>(b)</enum><header>Minimum direct care registered nurse-to-patient ratios</header> <paragraph id="H8974158DEB454600983A015E5519CC00"><enum>(1)</enum><header>In general</header><text>A hospital’s staffing plan shall provide that, 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, subject to paragraph (3):</text> <subparagraph id="H1474F31591034FE9AA0AB22E5D106123"><enum>(A)</enum><text>1 patient in operating room units and trauma emergency units.</text> </subparagraph><subparagraph id="H36151DAC326D44EEAE84DACD930D8DEC"><enum>(B)</enum><text>2 patients in critical care units, including emergency critical care and intensive care units, labor and delivery units, and postanesthesia units.</text> </subparagraph><subparagraph id="H05C6307902C449AA8DC7FA6061CCF49C"><enum>(C)</enum><text>3 patients in antepartum units, emergency room units, pediatrics units, stepdown units, and telemetry units.</text> </subparagraph><subparagraph id="H6C47D50D9CA6403CB862CB71EA156CB9"><enum>(D)</enum><text>4 patients in intermediate care nursery units, medical/surgical units, and acute care psychiatric units.</text> </subparagraph><subparagraph id="HDF68BE6E8B84420793026B7A98A48642"><enum>(E)</enum><text>5 patients in rehabilitation units.</text> </subparagraph><subparagraph id="H06E427ABD57E446CB6CD31F29873030C"><enum>(F)</enum><text>6 patients in postpartum (3 couplets) units and well-baby nursery units.</text> </subparagraph></paragraph><paragraph id="H9F2CF8A2158E421995217C2E0585E58C"><enum>(2)</enum><header>Similar units with different names</header><text>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.</text> </paragraph><paragraph id="H4EC196789FF14519B131296EDAC6E367"><enum>(3)</enum><header>Adjustment of ratios</header> <subparagraph id="H0BC68B35735B47059F74531608717A15"><enum>(A)</enum><header>In general</header><text>If necessary to protect patient safety, the Secretary may prescribe regulations that—</text> <clause id="H0E802A2A87E14AE8B2BEF1538DD62873"><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="HA3005788054B4807B084272F55F8620C"><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="H2329AB0328E344AA9EF92C22F43AE98B"><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="HBA4C4FA4FD4E48E6A86C92C7BEF69FDA"><enum>(4)</enum><header>Relationship to State-imposed ratios</header> <subparagraph id="H000AA4B9E4C84BE1AF1D04FE177DFCA1"><enum>(A)</enum><header>No preemption of certain State-imposed ratios</header><text>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> </subparagraph><subparagraph id="HFFA43F3D621F404D9A2AC02E499A63EA"><enum>(B)</enum><header>Satisfaction of certain Federal requirements with certain State-imposed nurse-to-patient ratios</header><text>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 licensed 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 requirements imposed under this subsection, so long as the particular licensed practical nurse is employed in the same or a comparable position.</text> </subparagraph></paragraph><paragraph id="HFAAFF2CEC5D843D498BDFF9CD9CD6C23"><enum>(5)</enum><header>Exemption in emergencies</header> <subparagraph id="H70778FDA85B042A68BA31D11A7AEE161"><enum>(A)</enum><header>In general</header><text>The requirements established under this subsection shall not apply during a declared state of emergency if a hospital is requested or expected to provide an exceptional level of emergency or other medical services.</text> </subparagraph><subparagraph id="HB5B0FBFC8EFD4B08A3741D729F82102A"><enum>(B)</enum><header>Emergency defined</header><text>For purposes of subparagraph (A), the term <term>declared state of emergency</term> means a state of emergency that has been declared by the Federal Government or the head of the appropriate State or local governmental agency having authority to declare that the State, county, municipality, or locality is in a state of emergency, but such term does not include a state of emergency that results from a labor dispute in the health care industry or consistent understaffing.</text> </subparagraph></paragraph></subsection><subsection id="H76C432535AD744F4B108E8425F281538"><enum>(c)</enum><header>Development and reevaluation of staffing plan</header> <paragraph id="H2311F39FE7EF442BB2FFA50AB0881B10"><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="H0A8629D8FB1245749F4E63D437F0C95E"><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 3106(1)), on a shift-by-shift basis.</text> </subparagraph><subparagraph id="H59FAA21A23604D069A4022354A62D6C7"><enum>(B)</enum><text>The anticipated admissions, discharges, and transfers of patients during each shift that impacts direct patient care.</text> </subparagraph><subparagraph id="HE85D2F4C865742879C138F3E30872C8E"><enum>(C)</enum><text>Specialized experience required of direct care registered nurses on a particular unit.</text> </subparagraph><subparagraph id="H70DA8F6DE7054289A5EFDAAB32F24DFE"><enum>(D)</enum><text>Staffing levels and services provided by other health care personnel in meeting direct patient care needs not required by a direct care registered nurse.</text> </subparagraph><subparagraph id="HFA259B155FA24210B4EBD64075039A1A"><enum>(E)</enum><text>The level of technology available that affects the delivery of direct patient care.</text> </subparagraph><subparagraph id="H4F9851F192D3417EB5E6F3D8727C105C"><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="HFA002C045BF342F7A6C77BF92071E2B5"><enum>(G)</enum><text>Obstacles to efficiency in the delivery of patient care presented by physical layout.</text> </subparagraph></paragraph><paragraph id="H0BFE3B840D09406FA036B09519FCDFB9"><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="H828A4D9EFC8048DCA141533B4685DA1B"><enum>(3)</enum><header>Annual reevaluation of plan and acuity system</header> <subparagraph id="HEDFAF83546EE47D9B3005F82FCF9F06A"><enum>(A)</enum><header>In general</header><text>A hospital shall annually evaluate—</text> <clause id="H02F95E13C8F340668C7DFE1412613582"><enum>(i)</enum><text>its staffing plan in each unit in relation to actual patient care requirements; and</text> </clause><clause id="H25F43DCE753E480781FAA60EE3FD7600"><enum>(ii)</enum><text>the accuracy of its acuity system.</text> </clause></subparagraph><subparagraph id="HEB9CAAFCA86042DD895A3DEAF32C52AF"><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="H177072D449174D1F8C95C0602B71D72D"><enum>(4)</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="HA8D2CD76398F46048FC59F32016BCDC8"><enum>(d)</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="H73D5EB11ABB94918AD1DE32EF0F56458"><enum>3102.</enum><header>Posting, records, and audits</header> <subsection id="HB70B153924AE41B89E9F2020ED766C84"><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="H7E4420018E6D460DB1C2A8D0A06D440A"><enum>(1)</enum><text>explains requirements imposed under section 3101;</text> </paragraph><paragraph id="H13DC0825241D42268D55B8E0EBAD5657"><enum>(2)</enum><text>includes actual direct care registered nurse-to-patient ratios during each shift; and</text> </paragraph><paragraph id="H82AF858360504AFC880E04F1C8A4D299"><enum>(3)</enum><text>is visible, conspicuous, and accessible to staff, patients, and the public.</text> </paragraph></subsection><subsection id="HFDE6E289C42A40A6B3CFEDCC60C57009"><enum>(b)</enum><header>Records</header> <paragraph id="HF4DCC6A306A34CD6926F0D72A022500E"><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="HDE89052A49CE40BB8FEA0BA569FCCC14"><enum>(A)</enum><text>the number of patients in each unit;</text> </subparagraph><subparagraph id="H7F1B0E753E474327873576893C5E9ECE"><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="HD64692736A90440ABCF35A5E354D6BEA"><enum>(C)</enum><text>a copy of each notice posted under subsection (a).</text> </subparagraph></paragraph><paragraph id="H3D36FC5660074762B3F6801B61C7D322"><enum>(2)</enum><header>Availability of records</header><text>Each hospital shall make its records maintained under paragraph (1) available to—</text> <subparagraph id="H89BC858FA2B1420990FEEA5A3FC31A8E"><enum>(A)</enum><text>the Secretary;</text> </subparagraph><subparagraph id="H4AD650A710D04C58BA3268B0C6A71CEF"><enum>(B)</enum><text>registered nurses and their collective bargaining representatives (if any); and</text> </subparagraph><subparagraph id="H8C1684E1B85C436EA77A281A0611B934"><enum>(C)</enum><text>the public under regulations established by the Secretary, or in the case of a federally operated hospital, under section 552 of title 5, United States Code (commonly known as the <quote>Freedom of Information Act</quote>).</text> </subparagraph></paragraph></subsection><subsection id="HB0BC4007429B45DA8F652A9EDCA297B6"><enum>(c)</enum><header>Audits</header><text>The Secretary shall conduct periodic audits to ensure—</text> <paragraph id="H2752A5F874F243BCA66876A6EDEB3802"><enum>(1)</enum><text>implementation of the staffing plan in accordance with this title; and</text> </paragraph><paragraph id="H3FB6218A4275403A909E936DC7E3691D"><enum>(2)</enum><text>accuracy in records maintained under this section.</text> </paragraph></subsection></section><section id="H47E7FA8C13804796859E46B4ED45F19A"><enum>3103.</enum><header>Minimum direct care licensed practical nurse staffing requirements</header> <subsection id="H9BD42652171A4F78996C8599B3DE1FDF"><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="H309A4521160A4ACA8EE4328D525F805B"><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="HE660178BAF7F4776A62A7F3ED76E9C66"><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 3101(b), section 3101(c), and section 3102 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 section 3101.</text> </subsection><subsection id="H2E9B9FB14E344D30B33BB55A5B968F7D"><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 <act-name parsable-cite="SSA">Social Security Act</act-name>), not later than 4 years after the date of the enactment of this title.</text> </subsection></section><section id="HE03555C697BD43D3AE2ED418F739E158"><enum>3104.</enum><header>Adjustment in reimbursement</header> <subsection id="HB82D4CFD00E346498A0E6AC36394F8F9"><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 <act-name parsable-cite="SSA">Social Security Act</act-name> 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 3101 through 3103. 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="HB7BDCBDFE6724FD88582E74F9D3963CD"><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 3101 through 3103.</text> </subsection><subsection id="HAAC03A845288479293A721145204C7E5"><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 <act-name parsable-cite="SSA">Social Security Act</act-name>) shall submit to Congress and the Secretary a report estimating total costs and savings attributable to compliance with requirements imposed under sections 3101 through 3103. Such report shall include recommendations on the need, if any, to adjust reimbursement for Medicare payments under subsection (a).</text> </subsection></section><section id="HDFAD324C36F54F11AA9B7B289898A509"><enum>3105.</enum><header>Protection of nurses and other individuals</header> <subsection id="HE8C828374BA84C0589B5FE4EF107BC5F"><enum>(a)</enum><header>Refusal of assignment</header><text>A nurse may refuse to accept an assignment as a nurse in a hospital if—</text> <paragraph id="H0CB85448E1D042ACA060205ECE1350E9"><enum>(1)</enum><text>the assignment would violate section 3101 or 3103; or</text> </paragraph><paragraph id="HB4A84D498AB04F798042F40FEB5CF4D9"><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="H724F53ADA9144D148C6690C85D305BC6"><enum>(b)</enum><header>Retaliation for refusal of assignment barred</header> <paragraph id="HEA69F5B677674582AC236B75D78078E5"><enum>(1)</enum><header>No discharge, discrimination, or retaliation</header><text>No hospital shall discharge, discriminate, or retaliate in any manner with respect to any aspect of employment (as defined in section 3106(5)), including discharge, promotion, compensation, or terms, conditions, or privileges of employment against a nurse based on the nurse’s refusal of a work assignment under subsection (a).</text> </paragraph><paragraph id="H82A0C3DC7D3F4E59B64BD5D4C89F24CD"><enum>(2)</enum><header>No filing of complaint</header><text>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 assignment under subsection (a).</text> </paragraph></subsection><subsection id="H2FFEBA90D2F34EEE814ED01B2CFD21F9"><enum>(c)</enum><header>Cause of action</header><text>Any nurse who has been discharged, discriminated, or retaliated against in violation 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:</text> <paragraph id="HD363733BA59047249BCD2DF4232A77F4"><enum>(1)</enum><text>Reinstatement.</text> </paragraph><paragraph id="HF9EDCB46502B45E9A51778517E5A819A"><enum>(2)</enum><text>Reimbursement of lost wages, compensation, and benefits.</text> </paragraph><paragraph id="H28AA84E2F7BD45449793DB0035750732"><enum>(3)</enum><text>Attorneys’ fees.</text> </paragraph><paragraph id="HF1ED2449091445E68D91079DFECD8A70"><enum>(4)</enum><text>Court costs.</text> </paragraph><paragraph id="H0AB6E3B475334084AE085BAACBA9ED09"><enum>(5)</enum><text>Other damages.</text> </paragraph></subsection><subsection id="H3F4E8C42E7BA4DB2BB5AE703BCAE8F28"><enum>(d)</enum><header>Complaint to Secretary</header><text>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—</text> <paragraph id="H314FDD4944D64610A5B44A8E4B57698D"><enum>(1)</enum><text>receive and investigate the complaint;</text> </paragraph><paragraph id="H9BE968F515384D949D8BC401BC449CFB"><enum>(2)</enum><text>determine whether a violation of this title as alleged in the complaint has occurred; and</text> </paragraph><paragraph id="HBA16B2A644B64C35BD45ED957DBFDAB9"><enum>(3)</enum><text>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).</text> </paragraph></subsection><subsection id="H11401B8AE2D14BD3827FF15995C38C43"><enum>(e)</enum><header>Protection for reporting</header> <paragraph id="HE09D8EC489F843AF9FAEC5084A1EBDC2"><enum>(1)</enum><header>Retaliation barred</header><text>A hospital shall not discriminate or retaliate in any manner with respect to any aspect of employment, including hiring, discharge, promotion, compensation, or terms, conditions, or privileges of employment against any individual who in good faith, individually or in conjunction with another person or persons—</text> <subparagraph id="HB28E1C8CC14C4B218F291DB40E076FAE"><enum>(A)</enum><text>reports a violation or a suspected violation of this title to the Secretary, a public regulatory agency, a private accreditation body, or the management personnel of the hospital;</text> </subparagraph><subparagraph id="H1CF8CBBD998946D0B2C916CAC0FC22D9"><enum>(B)</enum><text>initiates, cooperates, or otherwise participates in an investigation or proceeding brought by the Secretary, a public regulatory agency, or a private accreditation body concerning matters covered by this title; or</text> </subparagraph><subparagraph id="HC74105DB4A0B406AB5A5FD1230F310DA"><enum>(C)</enum><text>informs or discusses with other individuals or with representatives of hospital employees a violation or suspected violation of this title.</text> </subparagraph></paragraph><paragraph id="HDB87B911CA6D49E7B8EFAE9BFAA87F86"><enum>(2)</enum><header>Good faith defined</header><text>For purposes of this subsection, an individual shall be deemed to be acting in good faith if the individual reasonably believes—</text> <subparagraph id="H462D5A82989B4A138DD36B2B2BB93EBA"><enum>(A)</enum><text>the information reported or disclosed is true; and</text> </subparagraph><subparagraph id="H9F3542CEB2724199B27AF9E995680818"><enum>(B)</enum><text>a violation of this title has occurred or may occur.</text> </subparagraph></paragraph></subsection><subsection id="H8916CE6B6CC84472BDFB0F90F43A477F"><enum>(f)</enum><header>Notice</header><text>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="HDA3A315AFCA84C6DB21370A0605EA460"><enum>(1)</enum><text>explains the rights of nurses and other individuals under this section;</text> </paragraph><paragraph id="H63ED8574638C4E56B5F90213FBADBA54"><enum>(2)</enum><text>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</text> </paragraph><paragraph id="H6F3815EBC5E340EFA8DD3999B659ED71"><enum>(3)</enum><text>provides instructions on how to file a complaint under paragraph (2).</text> </paragraph></subsection><subsection id="HA093642C01254040B8D34EE755CD07AA"><enum>(g)</enum><header>Effective dates</header> <paragraph id="HC75791A3107648D0AF6FA4F082A7543D"><enum>(1)</enum><header>Refusal; retaliation; cause of action</header> <subparagraph id="HA1D5FAE400244E078D166B5001759E27"><enum>(A)</enum><header>In general</header><text>Subsections (a) through (c) shall apply to refusals occurring on or after the effective date of the provision to which the refusal relates.</text> </subparagraph><subparagraph id="H0FB1B5B853F641CFA69045735C8B750A"><enum>(B)</enum><header>Exception</header><text>Subsection (a)(2) shall not apply to refusals in any hospital before the requirements of section 3101(a) apply to that hospital.</text> </subparagraph></paragraph><paragraph id="H2A999DAFEBB04D5B8828C582581ADFE9"><enum>(2)</enum><header>Protections for reporting</header><text>Subsection (e) shall apply to actions described in subparagraphs (A) and (C) of subsection (e)(1) occurring 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.</text> </paragraph><paragraph id="HC9185E98CEF74C2698F38B0B59F39225"><enum>(3)</enum><header>Notice</header><text>Subsection (f) shall take effect 18 months after the date of the enactment of this title.</text> </paragraph></subsection></section><section id="H23CF23C59B034BBD9A4CB6E98FA955A2"><enum>3106.</enum><header>Definitions</header><text display-inline="no-display-inline">For purposes of this title:</text> <paragraph id="H781EB2CD6F3F4DF1A37D872D7E929EAC"><enum>(1)</enum><header>Acuity system</header><text>The term <term>acuity system</term> means an established measurement tool that—</text> <subparagraph id="H63175A268C6B42329DBDD9C488373796"><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="H38727EC640FF40778D28DBC44DA7FBB0"><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="H2C7774D3D16640648136451823F03BA5"><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="HC6EA3675B3DC44BF937E7A5F0246D92B"><enum>(D)</enum><text>is stated in terms that can be readily used and understood by nurses.</text> </subparagraph></paragraph><paragraph id="HD5307F1323B9486F88C37624F43AC6F2"><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 1 State to practice as a licensed practical nurse or a licensed vocational nurse and who provides bedside care for 1 or more patients.</text> </paragraph><paragraph id="H4C4C189DB6114ABAB6CDBD615177F537"><enum>(3)</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="H588E2ABD419D42AF93A204025A0BEA8E"><enum>(4)</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 1 State to practice as a registered nurse and who provides bedside care for 1 or more patients.</text> </paragraph><paragraph id="HFDF9CE8B86C84AE68454658FD1790877"><enum>(5)</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="H1012C4F863194F7898E229E2226BA81A"><enum>(6)</enum><header>Hospital</header><text>The term <term>hospital</term> has the meaning given that term in section 1861(e) of the <act-name parsable-cite="SSA">Social Security Act</act-name>, 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="H51E96F87307F4EA5AC07009025F7C58F"><enum>(7)</enum><header>Staffing plan</header><text>The term <term>staffing plan</term> means a staffing plan required under section 3101.</text> </paragraph></section>. (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 ensuring that sufficient numbers of nurses are available to meet the requirements imposed by title XXXI of the Public Health Service Act, as added by subsection (a).
3.
Enforcement of requirements through Federal programs
(a)
Medicare program
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 (U); (2)by striking the period at the end of subparagraph (V) and inserting , and; and (3)by inserting after subparagraph (V) the following: (W)in the case of a hospital, to comply with the provisions of title XXXI of the Public Health Service Act. . (b)
Medicaid program
The first sentence of 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 (71); (2)by striking the period at the end of paragraph (72) and inserting ; and; and (3)by inserting after paragraph (72) the following new paragraph: (73)provide that any hospital receiving payments under such plan must comply with the provisions of title XXXI of the Public Health Service Act. . (c)
Health benefits program of the Department 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 XXXI 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 XXX 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)
In general
Chapter 55 of title 10, United States Code, is amended by adding at the end the following new section:
1110a.
Staffing requirements
In the case of a facility of the uniformed services that is a hospital, the hospital shall comply with the provisions of title XXXI of the Public Health Service Act.
. (2)
Clerical amendment
The table of sections at the beginning of such chapter is amended by inserting after the item relating to section 1110 the following new item: 1110a. Staffing requirements. . (e)
Indian Health Services Program
Title 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:
826.
Staffing requirements
A hospital of the Service shall comply with the provisions of title XXXI of the Public Health Service Act.
. (f)
Federal labor-management relations
(1)
In general
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 XXXI of the Public Health Service Act through grievance procedures negotiated in accordance with section 7121. . (2)
Conforming amendment
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),.