[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 54 Introduced in Senate (IS)]







111th CONGRESS
  1st Session
                                 S. 54

To amend title XVIII of the Social Security Act to provide for patient 
  protection by establishing minimum nurse staffing ratios at certain 
              Medicare providers, and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                            January 6, 2009

  Mr. Inouye introduced the following bill; which was read twice and 
                  referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
To amend title XVIII of the Social Security Act to provide for patient 
  protection by establishing minimum nurse staffing ratios at certain 
              Medicare providers, 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 ``Registered Nurse Safe Staffing Act 
of 2009''.

SEC. 2. FINDINGS.

    Congress makes the following findings:
            (1) There are hospitals throughout the United States that 
        have inadequate staffing of registered nurses to protect the 
        well-being and health of the patients.
            (2) Studies show that the health of patients in hospitals 
        is directly proportionate to the number of registered nurses 
        working in the hospital.
            (3) There is a critical shortage of registered nurses in 
        the United States.
            (4) The effect of that shortage is revealed in unsafe 
        staffing levels in hospitals.
            (5) Patient safety is adversely affected by these unsafe 
        staffing levels, creating a public health crisis.
            (6) Registered nurses are being required to perform 
        professional services under conditions that do not support 
        quality health care or a healthful work environment for 
        registered nurses.
            (7) As a payer for inpatient and outpatient hospital 
        services for individuals entitled to benefits under the 
        Medicare program established under title XVIII of the Social 
        Security Act, the Federal Government has a compelling interest 
        in promoting the safety of such individuals by requiring any 
        hospital participating in such program to establish minimum 
        safe staffing levels for registered nurses.

SEC. 3. ESTABLISHMENT OF MINIMUM STAFFING RATIOS BY MEDICARE 
              PARTICIPATING HOSPITALS.

    (a) Requirement of Medicare Provider Agreement.--Section 1866(a)(1) 
of the Social Security Act (42 U.S.C. 1395cc(a)(1)) is amended--
            (1) in subparagraph (U), by striking ``and'' at the end;
            (2) in subparagraph (V), by striking the period at the end 
        and inserting ``, and''; and
            (3) by inserting after subparagraph (V) the following new 
        subparagraph:
            ``(W) in the case of a hospital, to meet the requirements 
        of section 1899.''.
    (b) Requirements.--Title XVIII of the Social Security Act is 
amended by inserting after section 1889 the following new section:

      ``staffing requirements for medicare participating hospitals

    ``Sec. 1899.  (a) Establishment of Staffing System.--
            ``(1) In general.--Each participating hospital shall adopt 
        and implement a staffing system that ensures a number of 
        registered nurses on each shift and in each unit of the 
        hospital to ensure appropriate staffing levels for patient 
        care.
            ``(2) Staffing system requirements.--Subject to paragraph 
        (3), a staffing system adopted and implemented under this 
        section shall--
                    ``(A) be based upon input from the direct care-
                giving registered nurse staff or their exclusive 
                representatives, as well as the chief nurse executive;
                    ``(B) be based upon the number of patients and the 
                level and variability of intensity of care to be 
                provided, with appropriate consideration given to 
                admissions, discharges, and transfers during each 
                shift;
                    ``(C) account for contextual issues affecting 
                staffing and the delivery of care, including 
                architecture and geography of the environment and 
                available technology;
                    ``(D) reflect the level of preparation and 
                experience of those providing care;
                    ``(E) account for staffing level effectiveness or 
                deficiencies in related health care classifications, 
                including but not limited to, certified nurse 
                assistants, licensed vocational nurses, licensed 
                psychiatric technicians, nursing assistants, aides, and 
                orderlies;
                    ``(F) reflect staffing levels recommended by 
                specialty nursing organizations;
                    ``(G) establish upwardly adjustable registered 
                nurse-to-patient ratios based upon registered nurses' 
                assessment of patient acuity and existing conditions;
                    ``(H) provide that a registered nurse shall not be 
                assigned to work in a particular unit without first 
                having established the ability to provide professional 
                care in such unit; and
                    ``(I) be based on methods that assure validity and 
                reliability.
            ``(3) Limitation.--A staffing system adopted and 
        implemented under paragraph (1) may not--
                    ``(A) set registered-nurse levels below those 
                required by any Federal or State law or regulation; or
                    ``(B) utilize any minimum registered nurse-to-
                patient ratio established pursuant to paragraph (2)(G) 
                as an upper limit on the staffing of the hospital to 
                which such ratio applies.
    ``(b) Reporting, and Release to Public, of Certain Staffing 
Information.--
            ``(1) Requirements for hospitals.--Each participating 
        hospital shall--
                    ``(A) post daily for each shift, in a clearly 
                visible place, a document that specifies in a uniform 
                manner (as prescribed by the Secretary) the current 
                number of licensed and unlicensed nursing staff 
                directly responsible for patient care in each unit of 
                the hospital, identifying specifically the number of 
                registered nurses;
                    ``(B) upon request, make available to the public--
                            ``(i) the nursing staff information 
                        described in subparagraph (A); and
                            ``(ii) a detailed written description of 
                        the staffing system established by the hospital 
                        pursuant to subsection (a); and
                    ``(C) submit to the Secretary in a uniform manner 
                (as prescribed by the Secretary) the nursing staff 
                information described in subparagraph (A) through 
                electronic data submission not less frequently than 
                quarterly.
            ``(2) Secretarial responsibilities.--The Secretary shall--
                    ``(A) make the information submitted pursuant to 
                paragraph (1)(C) publicly available, including by 
                publication of such information on the Internet website 
                of the Department of Health and Human Services; and
                    ``(B) provide for the auditing of such information 
                for accuracy as a part of the process of determining 
                whether an institution is a hospital for purposes of 
                this title.
    ``(c) Recordkeeping; Data Collection; Evaluation.--
            ``(1) Recordkeeping.--Each participating hospital shall 
        maintain for a period of at least 3 years (or, if longer, until 
        the conclusion of pending enforcement activities) such records 
        as the Secretary deems necessary to determine whether the 
        hospital has adopted and implemented a staffing system pursuant 
        to subsection (a).
            ``(2) Data collection on certain outcomes.--The Secretary 
        shall require the collection, maintenance, and submission of 
        data by each participating hospital sufficient to establish the 
        link between the staffing system established pursuant to 
        subsection (a) and--
                    ``(A) patient acuity from maintenance of acuity 
                data through entries on patients' charts;
                    ``(B) patient outcomes that are nursing sensitive, 
                such as patient falls, adverse drug events, injuries to 
                patients, skin breakdown, pneumonia, infection rates, 
                upper gastrointestinal bleeding, shock, cardiac arrest, 
                length of stay, and patient readmissions;
                    ``(C) operational outcomes, such as work-related 
                injury or illness, vacancy and turnover rates, nursing 
                care hours per patient day, on-call use, overtime 
                rates, and needle-stick injuries; and
                    ``(D) patient complaints related to staffing 
                levels.
            ``(3) Evaluation.--Each participating hospital shall 
        annually evaluate its staffing system and establish minimum 
        registered nurse staffing ratios to assure ongoing reliability 
        and validity of the system and ratios. The evaluation shall be 
        conducted by a joint management-staff committee comprised of at 
        least 50 percent of registered nurses who provide direct 
        patient care.
    ``(d) Enforcement.--
            ``(1) Responsibility.--The Secretary shall enforce the 
        requirements and prohibitions of this section in accordance 
        with the succeeding provisions of this subsection.
            ``(2) Procedures for receiving and investigating 
        complaints.--The Secretary shall establish procedures under 
        which--
                    ``(A) any person may file a complaint that a 
                participating hospital has violated a requirement or a 
                prohibition of this section; and
                    ``(B) such complaints are investigated by the 
                Secretary.
            ``(3) Remedies.--If the Secretary determines that a 
        participating hospital has violated a requirement of this 
        section, the Secretary--
                    ``(A) shall require the facility to establish a 
                corrective action plan to prevent the recurrence of 
                such violation; and
                    ``(B) may impose civil money penalties under 
                paragraph (4).
            ``(4) Civil money penalties.--
                    ``(A) In general.--In addition to any other 
                penalties prescribed by law, the Secretary may impose a 
                civil money penalty of not more than $10,000 for each 
                knowing violation of a requirement of this section, 
                except that the Secretary shall impose a civil money 
                penalty of more than $10,000 for each such violation in 
                the case of a participating hospital that the Secretary 
                determines has a pattern or practice of such violations 
                (with the amount of such additional penalties being 
                determined in accordance with a schedule or methodology 
                specified in regulations).
                    ``(B) Procedures.--The provisions of section 1128A 
                (other than subsections (a) and (b)) shall apply to a 
                civil money penalty under this paragraph in the same 
                manner as such provisions apply to a penalty or 
                proceeding under section 1128A.
                    ``(C) Public notice of violations.--
                            ``(i) Internet 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 
                        section, the violation for which the penalty 
                        was imposed, and such additional information as 
                        the Secretary determines appropriate.
                            ``(ii) Change of ownership.--With respect 
                        to a participating hospital that had a change 
                        in ownership, as determined by the Secretary, 
                        penalties imposed on the hospital while under 
                        previous ownership shall no longer be published 
                        by the Secretary of such Internet website after 
                        the 1-year period beginning on the date of 
                        change in ownership.
    ``(e) Whistleblower Protections.--
            ``(1) Prohibition of discrimination and retaliation.--A 
        participating hospital shall not discriminate or retaliate in 
        any manner against any patient or employee of the hospital 
        because that patient or employee, or any other person, has 
        presented a grievance or complaint, or has initiated or 
        cooperated in any investigation or proceeding of any kind, 
        relating to the staffing system or other requirements and 
        prohibitions of this section.
            ``(2) Relief for prevailing employees.--An employee of a 
        participating hospital who has been discriminated or retaliated 
        against in employment in violation of this subsection may 
        initiate judicial action in a United States district court and 
        shall be entitled to reinstatement, reimbursement for lost 
        wages, and work benefits caused by the unlawful acts of the 
        employing hospital. Prevailing employees are entitled to 
        reasonable attorney's fees and costs associated with pursuing 
        the case.
            ``(3) Relief for prevailing patients.--A patient who has 
        been discriminated or retaliated against in violation of this 
        subsection may initiate judicial action in a United States 
        district court. A prevailing patient shall be entitled to 
        liquidated damages of $5,000 for a violation of this statute in 
        addition to any other damages under other applicable statutes, 
        regulations, or common law. Prevailing patients are entitled to 
        reasonable attorney's fees and costs associated with pursuing 
        the case.
            ``(4) Limitation on actions.--No action may be brought 
        under paragraph (2) or (3) more than 2 years after the 
        discrimination or retaliation with respect to which the action 
        is brought.
            ``(5) Treatment of adverse employment actions.--For 
        purposes of this subsection--
                    ``(A) an adverse employment action shall be treated 
                as retaliation or discrimination; and
                    ``(B) the term `adverse employment action' 
                includes--
                            ``(i) the failure to promote an individual 
                        or provide any other employment-related benefit 
                        for which the individual would otherwise be 
                        eligible;
                            ``(ii) an adverse evaluation or decision 
                        made in relation to accreditation, 
                        certification, credentialing, or licensing of 
                        the individual; and
                            ``(iii) a personnel action that is adverse 
                        to the individual concerned.
    ``(f) Relationship to State Laws.--Nothing in this section shall be 
construed as exempting or relieving any person from any liability, 
duty, penalty, or punishment provided by any present or future law of 
any State or political subdivision of a State, other than any such law 
which purports to require or permit the doing of any act which would be 
an unlawful practice under this title.
    ``(g) Relationship to Conduct Prohibited Under the National Labor 
Relations Act or Other Collective Bargaining Laws.--Nothing in this 
section shall be construed as permitting conduct prohibited under the 
National Labor Relations Act or under any other Federal, State, or 
local collective bargaining law.
    ``(h) Regulations.--The Secretary shall promulgate such regulations 
as are appropriate and necessary to implement this section.
    ``(i) Definitions.--In this section:
            ``(1) Participating hospital.--The term `participating 
        hospital' means a hospital that has entered into a provider 
        agreement under section 1866.
            ``(2) Registered nurse.--The term `registered nurse' means 
        an individual who has been granted a license to practice as a 
        registered nurse in at least one State.
            ``(3) Unit.--The term `unit' of a hospital is an 
        organizational department or separate geographic area of a 
        hospital, such as a burn unit, a labor and delivery room, a 
        post-anesthesia service area, an emergency department, an 
        operating room, a pediatric unit, a stepdown or intermediate 
        care unit, a specialty care unit, a telemetry unit, a general 
        medical care unit, a subacute care unit, and a transitional 
        inpatient care unit.
            ``(4) Shift.--The term `shift' means a scheduled set of 
        hours or duty period to be worked at a participating hospital.
            ``(5) Person.--The term `person' means one or more 
        individuals, associations, corporations, unincorporated 
        organizations, or labor unions.''.
    (c) Effective Date.--The amendments made by this section shall take 
effect on January 1, 2010.
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