[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 1031 Introduced in Senate (IS)]

111th CONGRESS
  1st Session
                                S. 1031

    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 SENATE OF THE UNITED STATES

                              May 13, 2009

  Mrs. Boxer introduced the following bill; which was read twice and 
  referred to the Committee on Health, Education, Labor, and Pensions

_______________________________________________________________________

                                 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.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``National Nursing Shortage Reform and 
Patient Advocacy Act''.

SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE STAFFING REQUIREMENTS.

    (a) Minimum Direct Care Registered Nurse Staffing Requirements.--
The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by 
adding at the end the following new title:

      ``TITLE XXXI--MINIMUM DIRECT CARE REGISTERED NURSE STAFFING 
                              REQUIREMENTS

``SEC. 3101. MINIMUM NURSE STAFFING REQUIREMENTS.

    ``(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 protects 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 requirements under paragraph (1) 
                shall take effect not later than 1 year after the date 
                of enactment of this title.
                    ``(B) Application of minimum direct care registered 
                nurse-to-patient ratios.--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 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 
                enactment of this title.
    ``(b) Minimum Direct Care Registered Nurse-to-Patient Ratios.--
            ``(1) In general.--Except as otherwise provided in 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 shall be assigned to not more than the 
        following number of patients in that unit, subject to paragraph 
        (4):
                    ``(A) 1 patient in trauma emergency units.
                    ``(B) 1 patient in operating room units, provided 
                that a minimum of 1 additional person serves as a scrub 
                assistant in such unit.
                    ``(C) 2 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.
                    ``(D) 3 patients in emergency room units, stepdown 
                units, pediatrics units, telemetry units, and combined 
                labor, delivery, and postpartum units.
                    ``(E) 4 patients in antepartum units, intermediate 
                care nursery units, psychiatric units, and other 
                specialty care units.
                    ``(F) 5 patients in medical-surgical units, 
                rehabilitation units, and skilled nursing units.
                    ``(G) 8 patients in well-baby nursery units and 
                postpartum (4 couplets) 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) Restrictions.--
                    ``(A) Prohibition against averaging.--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.
                    ``(B) Prohibition against imposition of mandatory 
                overtime requirements.--A hospital shall not impose 
                mandatory overtime requirements to meet the hospital 
                unit direct care registered nurse-to-patient ratios 
                required under this subsection.
                    ``(C) Relief during routine absences.--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.
                    ``(D) Prohibition against imposition of lay-offs.--
                A hospital shall not impose lay-offs of licensed 
                vocational or practical nurses, licensed psychiatric 
                technicians, certified nursing assistants, or other 
                ancillary staff to meet the hospital unit direct care 
                registered nurse-to-patient ratios required under this 
                subsection.
            ``(4) Adjustment of ratios.--
                    ``(A) In general.--If necessary to protect patient 
                safety, the Secretary may prescribe regulations that--
                            ``(i) 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
                            ``(ii) add minimum direct care registered 
                        nurse-to-patient ratios for units not referred 
                        to in paragraphs (1) and (2).
                    ``(B) Consultation.--Such regulations shall be 
                prescribed after consultation with affected hospitals 
                and registered nurses.
            ``(5) No preemption of certain state-imposed ratios.--
        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.
            ``(6) Exemption in emergencies.--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.
    ``(c) Development and Reevaluation of Staffing Plan.--
            ``(1) Considerations in development of plan.--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:
                    ``(A) The number of patients and acuity level of 
                patients as determined by the application of an acuity 
                system (as defined in section 3107(1)), on a shift-by-
                shift basis.
                    ``(B) The anticipated admissions, discharges, and 
                transfers of patients during each shift that impacts 
                direct patient care.
                    ``(C) Specialized experience required of direct 
                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 during a shift.
                    ``(G) Obstacles to efficiency in the delivery of 
                patient care presented by physical layout.
            ``(2) Documentation of staffing.--A hospital shall specify 
        the system used to document actual staffing in each unit for 
        each shift.
            ``(3) Annual reevaluation of plan and acuity system.--
                    ``(A) In general.--A hospital shall annually 
                evaluate--
                            ``(i) its staffing plan in each unit in 
                        relation to actual patient care requirements; 
                        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) Transparency.--
                    ``(A) In general.--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.
                    ``(B) Public availability.--The Secretary shall 
                establish procedures to provide that the documentation 
                submitted under subsection (e) is available for public 
                inspection in its entirety.
            ``(5) 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 prohibited under the National Labor 
        Relations Act or under the Federal Labor Relations Act.
    ``(d) Acuity Tool.--
            ``(1) In general.--Not later than 2 years after the date of 
        enactment of the National Nursing Shortage Reform and Patient 
        Advocacy Act, the Secretary shall develop a national acuity 
        tool that provides a method for establishing nurse staffing 
        requirements above the hospital unit direct care registered 
        nurse-to-patient ratios required under subsection (b).
            ``(2) Implementation.--Each hospital 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.
    ``(e) Submission of Plan to Secretary.--A hospital shall submit to 
the Secretary its staffing plan required under subsection (a)(1) and 
any annual updates under subsection (c)(3)(B).

``SEC. 3102. POSTING, RECORDS, AND AUDITS.

    ``(a) Posting Requirements.--In each unit, a hospital shall post a 
uniform notice in a form specified by the Secretary in regulation 
that--
            ``(1) explains requirements imposed under section 3101;
            ``(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 hospital shall maintain 
        accurate records of actual direct care registered nurse-to-
        patient ratios in each unit for each shift for no less than 2 
        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 hospital shall make 
        its records maintained under paragraph (1) available to--
                    ``(A) the Secretary;
                    ``(B) registered nurses and their collective 
                bargaining representatives (if any); and
                    ``(C) 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 `Freedom of Information 
                Act').
    ``(c) Audits.--The Secretary shall conduct periodic audits to 
ensure--
            ``(1) implementation of the staffing plan in accordance 
        with this title; and
            ``(2) accuracy in records maintained under this section.

``SEC. 3103. 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 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 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.
    ``(c) Application of Registered Nurse Provisions to Licensed 
Practical Nurse Staffing Requirements.--Paragraphs (2), (4), (5)(A), 
and (6) 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 sections 3101 and 3102.
    ``(d) Effective Date.--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 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 
enactment of this title.

``SEC. 3104. FEDERAL ASSISTANCE FOR THE PURCHASE OF SAFE PATIENT 
              HANDLING EQUIPMENT.

    ``(a) In General.--The Secretary shall establish a grant program to 
provide financial assistance to cover some or all of the costs of 
purchasing safe patient handling equipment required by the Federal safe 
patient handling standard, developed under section 3 of the National 
Nursing Shortage Reform and Patient Advocacy Act, for health care 
facilities, such as hospitals, nursing facilities, and outpatient 
facilities, that--
            ``(1) require such equipment in order to comply with the 
        standards established under section 3 of the National Nursing 
        Shortage Reform and Patient Advocacy Act; and
            ``(2) demonstrate the financial inability to otherwise 
        afford the purchase of such equipment.
    ``(b) Application.--A health care facility desiring a grant under 
this section shall submit to the Secretary an application--
            ``(1) in such form and manner as the Secretary shall 
        specify; and
            ``(2) demonstrating true financial need, according to a 
        standard established by the Secretary.
    ``(c) Authorization of Appropriations.--There are authorized to be 
appropriated to be used for grant awards under this section $50,000,000 
for fiscal year 2010, which shall remain available until expended.

``SEC. 3105. WHISTLEBLOWER AND PATIENT PROTECTIONS.

    ``(a) Recognition of Duty and Right of Nurses To Advocate in the 
Exclusive Interest of the Patient.--A nurse shall have the right to act 
as the patient's advocate, as circumstances require, by--
            ``(1) initiating action to improve health care or to change 
        decisions or activities which, in the professional judgment of 
        the nurse, are against the interests and wishes of the patient; 
        and
            ``(2) giving the patient an opportunity to make informed 
        decisions about health care before it is provided.
    ``(b) Refusal of Assignment.--A nurse may refuse to accept an 
assignment as a nurse in a hospital if--
            ``(1) the assignment would violate section 3101 or 3103; or
            ``(2) 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.
    ``(c) Retaliation for Refusal of Assignment Barred.--
            ``(1) No discharge, discrimination, or retaliation.--No 
        hospital shall discharge, discriminate, or retaliate in any 
        manner with respect to any aspect of employment (as defined in 
        section 3107(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 (b).
            ``(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 assignment described in subsection (b).
    ``(d) Cause of Action.--Any nurse who has been discharged, 
discriminated against, or retaliated against in violation of subsection 
(c)(1) or against whom a complaint has been filed in violation of 
subsection (c)(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, compensation, and 
        benefits.
            ``(3) Attorneys' fees.
            ``(4) Court costs.
            ``(5) Other damages.
    ``(e) Complaint to Secretary.--
            ``(1) In general.--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--
                    ``(A) receive and investigate the complaint;
                    ``(B) determine whether a violation of this title 
                as alleged in the complaint has occurred; and
                    ``(C) if such a violation has occurred, issue an 
                order that the complaining nurse or individual shall 
                not suffer any retaliation described in subsection (c) 
                or subsection (g).
    ``(f) Toll-Free Telephone Number.--
            ``(1) In general.--The Secretary shall provide for the 
        establishment of a toll-free telephone hotline to provide 
        information regarding the requirements under section 3101 and 
        to receive reports of violations of such section.
            ``(2) Notice to patients.--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.
    ``(g) Protection for Reporting.--
            ``(1) Prohibition on retaliation or discrimination.--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.
            ``(2) Good faith defined.--For purposes of this subsection, 
        an individual shall be deemed to be acting in good faith if the 
        individual reasonably believes--
                    ``(A) the information reported or disclosed is 
                true; and
                    ``(B) a violation of this title has occurred or may 
                occur.
    ``(h) Prohibition on Interference With Rights.--
            ``(1) Exercise of rights.--It shall be unlawful for any 
        hospital to--
                    ``(A) interfere with, restrain, or deny the 
                exercise, or attempt to exercise, by any person of any 
                right provided or protected under this title; or
                    ``(B) coerce or intimidate any person regarding the 
                exercise or attempt to exercise such right.
            ``(2) Opposition to unlawful policies or practices.--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.
            ``(3) Prohibition on interference with protected 
        communications.--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 
        registered nurse from, or intimidates, coerces, or induces a 
        direct care registered nurse regarding, engaging in free speech 
        activities or disclosing information as provided under this 
        title.
            ``(4) Prohibition on interference with collective action.--
        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 (29 U.S.C. 157).
    ``(i) Notice.--A hospital shall post in an appropriate location in 
each unit a conspicuous notice in a form specified by the Secretary 
that--
            ``(1) explains the rights of nurses, patients, and other 
        individuals under this section;
            ``(2) 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
            ``(3) provides instructions on how to file a complaint 
        under paragraph (2).
    ``(j) Effective Dates.--
            ``(1) Refusal; retaliation; cause of action.--
                    ``(A) In general.--Subsections (b) through (d) 
                shall apply to refusals occurring on or after the 
                effective date of the provision to which the refusal 
                relates.
                    ``(B) Exception.--Subsection (b)(2) shall not apply 
                to refusals in any hospital before the requirements of 
                section 3101(a) apply to that hospital.
            ``(2) Protections for reporting.--Subsection (g)(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.
            ``(3) Notice.--Subsection (i) shall take effect 18 months 
        after the date of enactment of this title.

``SEC. 3106. ENFORCEMENT.

    ``(a) In General.--The Secretary shall enforce the requirements and 
prohibitions of this title in accordance with this section.
    ``(b) Procedures for Receiving and Investigating Complaints.--The 
Secretary shall establish procedures under which--
            ``(1) any person may file a complaint alleging that a 
        hospital has violated a requirement or a prohibition of this 
        title; and
            ``(2) such complaints shall be investigated by the 
        Secretary.
    ``(c) Remedies.--If the Secretary determines that a hospital has 
violated a requirement of this title, the Secretary--
            ``(1) shall require the facility to establish a corrective 
        action plan to prevent the recurrence of such violation; and
            ``(2) may impose civil money penalties, as described in 
        subsection (d).
    ``(d) Civil Penalties.--
            ``(1) In general.--In addition to any other penalties 
        prescribed by law, the Secretary may impose civil penalties as 
        follows:
                    ``(A) Hospital liability.--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).
                    ``(B) Individual liability.--The Secretary may 
                impose on an individual who--
                            ``(i) is employed by a hospital found by 
                        the Secretary to have violated a requirement of 
                        this title; and
                            ``(ii) willfully violates this title,
                a civil money penalty of not more than $20,000 for each 
                such violation.
            ``(2) Procedures.--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.
    ``(e) Public Notice of Violations.--
            ``(1) Internet website.--The Secretary shall publish on the 
        Internet website 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.
            ``(2) Change of ownership.--With respect to a participating 
        hospital that had a change in ownership, as determined by the 
        Secretary, penalties imposed on the hospital while under 
        previous ownership shall no longer be published by the 
        Secretary of such Internet website after the 1-year period 
        beginning on the date of change in ownership.
    ``(f) Offset.--Funds collected by the Secretary under this 
paragraph shall be used to offset the costs of enforcing this title.

``SEC. 3107. DEFINITIONS.

    ``For purposes of this title:
            ``(1) Acuity system.--The term `acuity system' means an 
        established measurement tool that--
                    ``(A) 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;
                    ``(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 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.
            ``(4) Direct care registered nurse.--The term `direct care 
        registered nurse' 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.
            ``(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 and 
        includes a long-term care hospital, as defined in section 
        1861(ccc) of such Act.
            ``(7) Staffing plan.--The term `staffing plan' means a 
        staffing plan required under section 3101.
            ``(8) Declared state of emergency.--The term `declared 
        state of emergency' 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, 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.

``SEC. 3108. RULE OF CONSTRUCTION.

    ``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.''.
    (b) Recommendations to Congress.--Not 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 XXXI of the Public Health Service 
Act, as added by subsection (a).

SEC. 3. FEDERAL SAFE PATIENT HANDLING STANDARD.

    (a) In General.--Not later than 1 year after the date of enactment 
of this Act, the Secretary of Labor, acting through the Director of 
Occupational Safety and Health Administration, shall establish a 
Federal Safe Patient Handling Standard, consistent with section 6 of 
the Occupational Safety and Health Act of 1970 (29 U.S.C. 655) to 
prevent musculoskeletal disorders for direct care registered nurses and 
other health care providers working in health care facilities.
    (b) Development of Standard.--In developing the standard under 
subsection (a), the Secretary shall solicit input from direct care 
registered nurses and organizations representing direct care registered 
nurses in implementing the standard.
    (c) Requirements.--The standard promulgated under subsection (a) 
shall include--
            (1) a zero lift policy;
            (2) a musculoskeletal injury prevention plan, which shall 
        include hazard identification and risk assessments in relation 
        to patient care duties and patient handling;
            (3) a program to identify problems and solutions regarding 
        safe patient handling;
            (4) a system to report, track, and analyze trends in 
        injuries, as well as make injury data available to the public;
            (5) training for staff, including interactive classroom-
        based and hands-on training by a knowledgeable person or staff, 
        on safe patient handling policies, equipment, and devices at 
        least on an annual basis, which shall include training on 
        hazard identification, assessment, and control of 
        musculoskeletal hazards in patient care areas; and
            (6) annual evaluations of safe patient handling efforts, as 
        well as new technology, handling procedures, and engineering 
        controls.
    (d) Compliance With the Standard.--The Secretary of Labor shall 
require--
            (1) all health care facilities to comply with the standard 
        developed under subsection (a); and
            (2) health care facilities to purchase, use, and maintain 
        safe lift mechanical devices.
    (e) Safe Patient Handling Plan.--In accordance with the standard 
developed under subsection (a), and not later than 180 days after such 
standard is published, health care facilities shall develop and 
implement a safe patient handling plan that--
            (1) provides adequate, appropriate, and quality delivery of 
        health care services that protects patient safety and prevents 
        musculoskeletal disorders for direct care registered nurses and 
        other health care providers;
            (2) is consistent with the requirements of the Federal Safe 
        Patient Handling Standard;
            (3) provides for input by direct care registered nurses and 
        organizations representing direct care registered nurses in 
        implementing the plan; and
            (4) ensures that safe lifting mechanical devices shall only 
        be used by direct care registered nurses and other health care 
        providers.
    (f) Definitions.--In this section--
            (1) the term ``lift team'' means employees of a hospital 
        who are specially trained to handle patient lifts, repositions, 
        and transfers using patient transfer devices or lifting devices 
        as appropriate for the specific patient, based on a needs 
        assessment of the individual hospital employer; and
            (2) the term ``zero lift policy'' means replacing 
        unassisted manual lifting, repositioning, and transferring of 
        patients with the use of patient transfer devices, lifting 
        devices, and lift teams. Such term does not require the use of 
        patient transfer or lifting devices when the lift, reposition, 
        and transfer needs assessment indicates it is safe for the 
        patient and the employee to use manual lifting, repositioning, 
        and transferring techniques.

SEC. 4. PAYMENT ADJUSTMENT FOR HOSPITALS UNDER THE MEDICARE PROGRAM 
              BASED ON ADDITIONAL COSTS OF COMPLYING WITH CERTAIN 
              REQUIREMENTS.

    Section 1886 of the Social Security Act (42 U.S.C. 1395ww), as 
amended by section 4102 of the HITECH Act (Public Law 111-5), is 
amended by adding at the end the following new subsection:
    ``(o) Adjustment Based on Additional Costs of Complying With 
Certain Requirements.--
            ``(1) In general.--With respect to inpatient hospital 
        services furnished by a subsection (d) hospital during a fiscal 
        year (beginning with fiscal year 2010), in addition to the 
        amount otherwise paid under this section, there shall also be 
        paid to the subsection (d) hospital, from the Federal Hospital 
        Insurance Trust Fund established under section 1817, an amount 
        equal to the applicable amount specified in paragraph (2) for 
        the subsection (d) hospital for the fiscal year.
            ``(2) Applicable amount.--The applicable amount specified 
        in this paragraph for a subsection (d) hospital for a fiscal 
        year is equal to the quotient of--
                    ``(A) the total amount of additional costs incurred 
                by the hospital in providing inpatient hospital 
                services to beneficiaries during the fiscal year that 
                are attributable to compliance with the requirements 
                under sections 3101, 3102, and 3103 of the Public 
                Health Services Act (as estimated by the Secretary, 
                taking into account recommendations contained in the 
                report under paragraph (3)); and
                    ``(B) the total number of discharges during the 
                fiscal year (as estimated by the Secretary).
            ``(3) Medicare payment advisory commission report.--Not 
        later than 2 years after the date of the enactment of this 
        subsection, the Medicare Payment Advisory Commission shall 
        submit to Congress and the Secretary a report containing an 
        estimate of the total costs to and savings for subsection (d) 
        hospitals during a fiscal year that are attributable to 
        compliance with the requirements under sections 3101, 3102, and 
        3103 of the Public Health Service Act, including 
        recommendations regarding the adjustment in payments to such 
        hospitals under this subsection, together with recommendations 
        for such legislation and administrative action as the 
        Commission determines appropriate.''.

SEC. 5. 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 be subject to 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)), as amended by section 
5006(e)(2)(A) of Division B of the American Recovery and Reinvestment 
Act of 2009 (Public Law 111-5), is amended--
            (1) by striking ``and'' at the end of paragraph (72);
            (2) by striking the period at the end of paragraph (73) and 
        inserting ``; and''; and
            (3) by inserting after paragraph (73) the following new 
        paragraph:
            ``(74) provide that any hospital receiving payments under 
        such plan shall be subject to the provisions of title XXXI of 
        the Public Health Service Act.''.

SEC. 6. REGISTERED NURSE WORKFORCE INITIATIVE.

    Title VIII of the Public Health Service Act (42 U.S.C. 296 et seq.) 
is amended by adding at the end the following:

            ``PART J--REGISTERED NURSE WORKFORCE INITIATIVE

``SEC. 860. REGISTERED NURSE WORKFORCE INITIATIVE.

    ``(a) Establishment.--The Secretary, acting through the 
Administrator of the Health Resources and Services Administration, 
shall carry out a Registered Nurse Workforce Initiative (referred to in 
this part as the `RNWI') to ensure that there is an adequate number of 
registered nurses and to reduce critical workforce shortages in 
hospitals.
    ``(b) Purposes.--The purposes of the RNWI are to--
            ``(1) achieve short-term mitigation and remedy of the 
        nationwide nursing shortage; and
            ``(2) establish and maintain the necessary educational 
        system foundations and institutional involvement to ensure 
        sufficient labor supply and labor market stability essential to 
        ensuring safe and competent hospital nursing care on an ongoing 
        basis.
    ``(c) Duration.--The RNWI is established as a 5-year program for 
the purpose of adding new registered nurses to the workforce, and may 
be extended beyond the initial 5-year period, if the Secretary 
determines appropriate.

``SEC. 861. EDUCATIONAL ASSISTANCE BENEFITS.

    ``(a) Grants for Associate and Baccalaureate Degree Programs.--
            ``(1) Basic educational assistance benefits.--To address 
        the critical shortage of direct care registered nurses, the 
        Secretary shall establish a nursing educational assistance 
        grant program for eligible individuals who are accepted to, or 
        are enrolled in, associate and baccalaureate degrees in nursing 
        programs, based on such individuals' financial need, as 
        determined by the Secretary.
            ``(2) Supplemental educational assistance benefit.--
                    ``(A) Benefits.--Each individual awarded a grant 
                under this subsection shall receive--
                            ``(i) nursing educational assistance to 
                        help meet, in part, the annual expenses of 
                        enrolling in and attending an associate or a 
                        baccalaureate degree in nursing program; and
                            ``(ii) a monthly living stipend to help 
                        meet the individual's basic living expenses.
                    ``(B) Grant amounts.--The Secretary shall determine 
                the amounts awarded under subparagraph (A) for each 
                fiscal year, based upon the cost of living and the cost 
                of attending a nursing program for such fiscal year.
            ``(3) Eligibility.--An individual desiring a grant under 
        this subsection shall--
                    ``(A) be an individual who has been accepted to an 
                accredited nursing education program;
                    ``(B) provide assurances that such individual will 
                work for a health care provider that is eligible to 
                receive national health service corps professionals for 
                a period of not less than 3 years, in a setting that 
                the Secretary determines appropriate; and
                    ``(C) submit to the Secretary an application at 
                such time, in such manner, and containing such 
                information as the Secretary may require.
    ``(b) Grants for Advance Degrees in Nursing.--
            ``(1) In general.--To address the critical shortage of 
        nurse educators holding master's or doctoral degrees in 
        nursing, as well as the lack of master's and doctoral nursing 
        students, the Secretary shall establish a program to award 
        grants to eligible individuals to assist such individuals in 
        pursuing graduate nursing degrees.
            ``(2) Eligible individuals.--An individual desiring a grant 
        under this section shall--
                    ``(A) hold an unencumbered license as a registered 
                nurse;
                    ``(B) be accepted into an accredited master's or 
                doctorate degree program in nursing;
                    ``(C) provide assurances that such individual will 
                work as a nurse educator at an accredited nursing 
                program for a period of 5 years after graduating from 
                an accredited graduate degree program in nursing; and
                    ``(D) submit to the Secretary an application at 
                such time, in such manner, and containing such 
                information as the Secretary may require.
    ``(c) Repayment Obligation.--A recipient of a grant under this 
section who fails to meet the requirements of the grant, as described 
in this section or as specified by the Secretary, shall repay the 
Secretary all amounts received through such grant, with interest.

``SEC. 862. PRECEPTORSHIP AND MENTORSHIP DEMONSTRATION PROJECTS.

    ``(a) In General.--The Secretary shall award grants to eligible 
entities for the purpose of conducting 5-year nursing preceptorship and 
mentorship demonstration projects, designed to address nurse workforce 
shortages and improve patient care by providing additional support to 
nurses entering the workforce to promote the retention of nurses in the 
workforce.
    ``(b) Eligible Entities.--An entity desiring a grant under this 
section shall--
            ``(1) be a hospital; and
            ``(2) submit an application to the Secretary at such time, 
        in such manner, and containing such information as the 
        Secretary may require.
    ``(c) Priority.--In awarding grants under this section, the 
Secretary shall give priority to hospitals that have a critical 
shortage of nurses, as determined by the Secretary.
    ``(d) Preceptorship Program.--
            ``(1) In general.--The preceptorship program shall 
        provide--
                    ``(A) a period of practical experience and training 
                for nursing students, by providing clinical supervision 
                by a direct care registered nurse expert or specialist 
                in a particular field; or
                    ``(B) a period of orientation for newly-graduated 
                or newly hired direct care registered nurses.
            ``(2) Purpose.--The purpose of the preceptorship program is 
        to establish a period of practical and clinical experiences and 
        training for nursing students, newly hired nurses and recent 
        graduates of a direct care degree program for registered 
        nurses.
    ``(e) Mentorship Program.--
            ``(1) In general.--The mentorship program shall match newly 
        hired direct care registered nurses (referred to in this 
        subsection as the `mentees') with experienced direct care 
        registered nurses, who shall serve as advocates and role models 
        and help the mentees grow professionally, feel supported, and 
        adapt to the culture of the acute care hospital. Mentors shall 
        provide personal and career support in the workplace.
            ``(2) Purpose.--The purpose of the mentorship program is to 
        assist new or transitional direct care registered nurses to 
        succeed in making their own contributions to the care of 
        patients and to the nursing profession.
    ``(f) Report.--Each recipient of a grant under this section, at the 
end of such recipient's 5-year demonstration project, shall submit to 
the Secretary a report containing an evaluation of the effect of the 
demonstration project on nurse retention and patient care in the 
hospital for which such grant was awarded.

``SEC. 863. AUTHORIZATION OF APPROPRIATIONS.

    ``To carry out this part, there are authorized to be appropriated 
such funds as may be necessary for fiscal years 2010 through 2014.''.
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