1.This Act may be cited as the
National Nursing Shortage Reform and
Patient Advocacy Act
.
2.Minimum direct
care registered nurse staffing requirements
(a)Minimum direct
care registered nurse staffing requirementsThe
Public Health Service Act (42 U.S.C.
201 et seq.) is amended by adding at the end the following new title:
<enum>XXXIV</enum><header>Minimum direct
care registered nurse staffing requirements</header>
<section id="H18214705752F4F91BCA2B84F4991628E"><enum>3401.</enum><header>Minimum nurse
staffing requirements</header>
<subsection id="HDB8F9B1E7F1D4349B050B9327ED52EE0"><enum>(a)</enum><header>Staffing
plan</header>
<paragraph id="H5F7EDD9B6F434AE5BF5DB3B7BE001289"><enum>(1)</enum><header>In
general</header><text>A hospital shall implement a staffing plan that—</text>
<subparagraph id="H377C1A9BC90E4888B58786BFC800CD5D"><enum>(A)</enum><text>provides adequate,
appropriate, and quality delivery of health care services and protects patient
safety; and</text>
</subparagraph><subparagraph id="HA755017A7DF0455BBE4128007E87D5B9"><enum>(B)</enum><text>is consistent with
the requirements of this title.</text>
</subparagraph></paragraph><paragraph id="H53D5346067B44B2CA35520FB508DC03B"><enum>(2)</enum><header>Effective
dates</header>
<subparagraph id="HC9CA1652321943A7A3F4B72B930051E0"><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
enactment of this title.</text>
</subparagraph><subparagraph id="HA81D8A9E099441B880749F895FCA9118"><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
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 enactment of
this title.</text>
</subparagraph></paragraph></subsection><subsection id="HBC263A2A812A4DC9AA4CB8F04F8E1CE8"><enum>(b)</enum><header>Minimum direct
care registered nurse-to-Patient ratios</header>
<paragraph id="H2FB4063071DD44B8BBCF00A542368250"><enum>(1)</enum><header>In
general</header><text>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):</text>
<subparagraph id="H0957BA767CA94636A510D974FC1833AE"><enum>(A)</enum><text>One patient in
trauma emergency units.</text>
</subparagraph><subparagraph id="id84A21B45C2494CECAE03CF6BB0DB452A"><enum>(B)</enum><text>One patient in
operating room units, provided that a minimum of 1 additional person serves as
a scrub assistant in such unit.</text>
</subparagraph><subparagraph id="H87AF171874D24FF80033B697DA6523E6"><enum>(C)</enum><text>Two patients in
critical care units, including neonatal intensive care units, emergency
critical care and intensive care units, labor and delivery units, coronary care
units, acute respiratory care units, postanesthesia units, and burn
units.</text>
</subparagraph><subparagraph id="H084B2BBB9D2C4CE7A36DF8133DA4C85B"><enum>(D)</enum><text>Three patients in
emergency room units, stepdown units, pediatrics units, telemetry units,
antepartum units, and combined labor, delivery, and postpartum units.</text>
</subparagraph><subparagraph id="HD9E02E1C514A44269F94BC005B20B1FF"><enum>(E)</enum><text>Four patients in
medical-surgical units, intermediate care nursery units, psychiatric units, and
other specialty care units.</text>
</subparagraph><subparagraph id="HF5C68FE5E38B4866B3F12744EA313D94"><enum>(F)</enum><text>Five patients in
rehabilitation units, and skilled nursing units.</text>
</subparagraph><subparagraph id="HC8FD0DD2D47040889FBB19BF37D634DA"><enum>(G)</enum><text>Six patients in
well-baby nursery units and postpartum (3 couplets) units.</text>
</subparagraph></paragraph><paragraph id="HDEE53A5D7DD24DEF9576DA4D5781CCF"><enum>(2)</enum><header>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 provides a
level of care to patients whose needs are similar to the needs of patients
cared for in any unit referred to in such paragraph.</text>
</paragraph><paragraph id="id4AB455CDD4D94FBF972054DDEC6A394B"><enum>(3)</enum><header>Restrictions</header>
<subparagraph id="id1956B33F60FE45C4A92E929722B63EF6"><enum>(A)</enum><header>Prohibition
against averaging</header><text>A hospital shall not average the number of
patients and the total number of direct care registered nurses assigned to
patients in a hospital unit during any 1 shift or over any period of time for
purposes of meeting the requirements under this subsection.</text>
</subparagraph><subparagraph id="id5EE68AEF01304910B290C696522FD5A7"><enum>(B)</enum><header>Prohibition
against imposition of mandatory overtime requirements</header><text>A hospital
shall not impose mandatory overtime requirements to meet the hospital unit
direct care registered nurse-to-patient ratios required under this
subsection.</text>
</subparagraph><subparagraph id="id8D11D0A956D549568CE8651EA1B4094D"><enum>(C)</enum><header>Relief during
routine absences</header><text>A hospital shall ensure that only a direct care
registered nurse may relieve another direct care registered nurse during
breaks, meals, and other routine, expected absences from a hospital
unit.</text>
</subparagraph></paragraph><paragraph id="HB3CF1BD9D244493A8E16CA0080E411DD"><enum>(4)</enum><header>Adjustment of
ratios</header>
<subparagraph id="H1A763CF34C9D41958CC7D4E078E613D6"><enum>(A)</enum><header>In
general</header><text>If necessary to protect patient safety, the Secretary may
prescribe regulations that—</text>
<clause id="H26A79A023CF2497DBA500098E0A263E9"><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="H60E0E9B0DFBA430B85B19EE38433F690"><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="H00FBE7A252BB4DD08E3896C8A8008F86"><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="H1523BC5F08684A2AA9D5FBB9D86B0525"><enum>(5)</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>
</paragraph><paragraph id="HCADFBB916292453D00DD1881F5F25BE"><enum>(6)</enum><header>Exemption in
emergencies</header>
<subparagraph id="idEE2441AAE8EF492F81FA5A247618137C"><enum>(A)</enum><header>In
general</header><text>The requirements established under this subsection shall
not apply during a state of emergency if a hospital is requested or expected to
provide an exceptional level of emergency or other medical services.</text>
</subparagraph><subparagraph id="id5A05B93A659B4F74A7D8F1952B1778A8"><enum>(B)</enum><header>Guidance</header><text>The
Secretary shall issue guidance to hospitals that describes situations that
constitute a state of emergency for purposes of the exemption under this
paragraph.</text>
</subparagraph></paragraph></subsection><subsection id="H13CB67F10095468882F66675CE17826"><enum>(c)</enum><header>Development and
reevaluation of staffing plan</header>
<paragraph id="HEC447D2FE90445628CE7CD58DDAF00"><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="HE5ED4F6D3BF74235BEF5191DA2D2FAC2"><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 3407(1)), on a shift-by-shift
basis.</text>
</subparagraph><subparagraph id="H1A48C605B1D94804B5AB555EB754F6D"><enum>(B)</enum><text>The anticipated
admissions, discharges, and transfers of patients during each shift that
impacts direct patient care.</text>
</subparagraph><subparagraph id="H823415E491AF4A989281C97B842B2BAF"><enum>(C)</enum><text>Specialized
experience required of direct care registered nurses on a particular
unit.</text>
</subparagraph><subparagraph id="H3FD90EF6FAEC426381AA22E57540955C"><enum>(D)</enum><text>Staffing levels
and services provided by licensed vocational or practical nurses, licensed
psychiatric technicians, certified nurse assistants, or other ancillary staff
in meeting direct patient care needs not required by a direct care registered
nurse.</text>
</subparagraph><subparagraph id="H444208C46828459C81DB22B749BAB705"><enum>(E)</enum><text>The level and
quality of technology available that affects the delivery of direct patient
care.</text>
</subparagraph><subparagraph id="HC98253D13C2E424E8087DF2F21933B36"><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="H41F929568464491D001483086BD1604"><enum>(G)</enum><text>Obstacles to
efficiency in the delivery of patient care presented by physical layout.</text>
</subparagraph></paragraph><paragraph id="H4F521DC9031243B4A6CAC28C8238AA9D"><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="H2E572DA1F33344B283003200C85B9267"><enum>(3)</enum><header>Annual
reevaluation of plan and acuity system</header>
<subparagraph id="H374D2307B0F94612B2008FF7EE1E7902"><enum>(A)</enum><header>In
general</header><text>A hospital shall annually evaluate—</text>
<clause id="H743D20FBF23B449495B43034CC44E000"><enum>(i)</enum><text>its staffing plan
in each unit in relation to actual patient care requirements; and</text>
</clause><clause id="H2194597C304A490E00F96F7CA65F2376"><enum>(ii)</enum><text>the accuracy of
its acuity system.</text>
</clause></subparagraph><subparagraph id="H7DF324DE7A454C33B1411DF65BD7AA85"><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="id4C71EE4C6764428FA552B4AFF9B9B58B"><enum>(4)</enum><header>Transparency</header>
<subparagraph id="id9DA72FAE3F0F47148338B203689E156D"><enum>(A)</enum><header>In
general</header><text>Any acuity-based patient classification system adopted by
a hospital under this section shall be transparent in all respects, including
disclosure of detailed documentation of the methodology used to predict nursing
staffing, identifying each factor, assumption, and value used in applying such
methodology.</text>
</subparagraph><subparagraph id="id6A8DA1A7FB9142FC8622EE456A52D897"><enum>(B)</enum><header>Public
availability</header><text>The Secretary shall establish procedures to provide
that the documentation submitted under subsection (e) is available for public
inspection in its entirety.</text>
</subparagraph></paragraph><paragraph id="H901A570DBE264C9F945F623BCF2C923D"><enum>(5)</enum><header>Registered nurse
participation</header><text>A staffing plan of a hospital shall be developed
and subsequent reevaluations shall be conducted under this subsection on the
basis of input from direct care registered nurses at the hospital or, where
such nurses are represented through collective bargaining, from the applicable
recognized or certified collective bargaining representative of such nurses.
Nothing in this title shall be construed to permit conduct prohibited under the
National Labor Relations Act or under the Federal Labor Relations Act.</text>
</paragraph></subsection><subsection id="idD2FCDE9893FB449E8AA6D5BFD7E92F50"><enum>(d)</enum><header>Acuity
tool</header>
<paragraph id="id123EF8304C1A499DBD4B550133D8BD8C"><enum>(1)</enum><header>In
general</header><text>Not later than 2 years after the date of enactment of the
<short-title>National Nursing Shortage Reform and Patient
Advocacy Act</short-title>, the Secretary shall develop a national acuity tool
that provides a transparent method for establishing nurse staffing requirements
above the hospital unit direct care registered nurse-to-patient ratios required
under subsection (b).</text>
</paragraph><paragraph id="idE3F2B629ABF94A4A9623BE6C7DCF4373"><enum>(2)</enum><header>Implementation</header><text>Each
hospital may adopt and implement the national acuity tool described in
paragraph (1), and provide staffing based on such tool. Any additional direct
care registered nursing staffing above the hospital unit direct care registered
nurse-to-patient ratios described in subsection (b) shall be assigned in a
manner determined by such national acuity tool.</text>
</paragraph></subsection><subsection id="id15CE8BFC71AF42C3BDFC91B199074208"><enum>(e)</enum><header>Submission of
plan to Secretary</header><text>A hospital shall submit to the Secretary its
staffing plan required under subsection (a)(1) and any annual updates under
subsection (c)(3)(B).</text>
</subsection></section><section id="H6BF366EA2144424B95B1E78B3FD5CF68"><enum>3402.</enum><header>Posting,
records, and audits</header>
<subsection id="H5B75A03E1FC44D5299F3065511010087"><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="H75A0F9A184BB4BB18B67BC3C9D783389"><enum>(1)</enum><text>explains
requirements imposed under section 3401;</text>
</paragraph><paragraph id="H6783410D9F6B4DE282B09200FBD82E39"><enum>(2)</enum><text>includes actual
direct care registered nurse-to-patient ratios during each shift; and</text>
</paragraph><paragraph id="H6D81C8B2D58C45B69EF48CF69279B300"><enum>(3)</enum><text>is visible,
conspicuous, and accessible to staff, patients, and the public.</text>
</paragraph></subsection><subsection id="H65D87976940F44E9ABCC16FF15C1A2B"><enum>(b)</enum><header>Records</header>
<paragraph id="H15B5E0820F394A0C876CA1007084FCF1"><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 2 years. Such records shall include—</text>
<subparagraph id="HBD953AF5174D4EA1B04145EBBE8120E2"><enum>(A)</enum><text>the number of
patients in each unit;</text>
</subparagraph><subparagraph id="H49446DE55D2148D19719A7D1505D7B53"><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="HF883739500404B1B89B3032D8E7E20EA"><enum>(C)</enum><text>a copy of each
notice posted under subsection (a).</text>
</subparagraph></paragraph><paragraph id="HFCF72B42E4DB4E5DA0F5A222824B7C17"><enum>(2)</enum><header>Availability of
records</header><text>Each hospital shall make its records maintained under
paragraph (1) available to—</text>
<subparagraph id="H3DC9131CFC96424DADEB376DEFCB0447"><enum>(A)</enum><text>the
Secretary;</text>
</subparagraph><subparagraph id="H04B4371331B44DBD8169981C67FA084C"><enum>(B)</enum><text>registered nurses
and their collective bargaining representatives (if any); and</text>
</subparagraph><subparagraph id="H192E84171C91406BBA1800CF532C1400"><enum>(C)</enum><text>the public under
regulations established by the Secretary, or in the case of a federally
operated hospital, under
<external-xref legal-doc="usc" parsable-cite="usc/5/552">section
552</external-xref> of title 5, United States Code (commonly known as the
<quote>Freedom of Information Act</quote>).</text>
</subparagraph></paragraph></subsection><subsection id="H1BF498A509D04E7DBEECE13EDCE1914F"><enum>(c)</enum><header>Audits</header><text>The
Secretary shall conduct periodic audits to ensure—</text>
<paragraph id="H0A72C153E21147919D2834FCBBC4674B"><enum>(1)</enum><text>implementation of
the staffing plan in accordance with this title; and</text>
</paragraph><paragraph id="H28AA16B9017E4072BDAEA642C5480988"><enum>(2)</enum><text>accuracy in
records maintained under this section.</text>
</paragraph></subsection></section><section id="HA035B6D5AE574BFDBB0669709E33357F"><enum>3403.</enum><header>Minimum direct
care licensed practical nurse staffing requirements</header>
<subsection id="HE4377D33B8DC425687007E747CC067B"><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 enactment of this title, and shall be based on the
study conducted under subsection (b).</text>
</subsection><subsection id="H7A3D74F7A7CD4D3CBC7195E24BD8EB"><enum>(b)</enum><header>Study</header><text>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.</text>
</subsection><subsection id="HC4256DAA9A5A4F45B746FCD376382B07"><enum>(c)</enum><header>Application of
registered nurse provisions to licensed practical nurse staffing
requirements</header><text>Paragraphs (2), (4), (5)(A), and (6) of section
3401(b), section 3401(c), and section 3402 shall apply to the establishment and
application of direct care licensed practical nurse staffing requirements under
this section in the same manner that they apply to the establishment and
application of direct care registered nurse-to-patient ratios under sections
3401 and 3402.</text>
</subsection><subsection id="H34C0CBED9E71481080A6BE1BE69EF4D7"><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 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 enactment of this title.</text>
</subsection></section><section id="idBC8F947663FC4211BD244E9C81E18D9B"><enum>3404.</enum><header>Adjustment in
reimbursement</header>
<subsection id="id2DCEB009A81F4C26A32950E30710A04E"><enum>(a)</enum><header>Medicare
reimbursement</header><text>The Secretary shall adjust payments made to
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 3401
through 3403. The amount of such payment adjustments shall take into account
recommendations contained in the report submitted by the Medicare Payment
Advisory Commission under subsection (b).</text>
</subsection><subsection id="id870709278C0D4AEF9C94C3B20FB43756"><enum>(b)</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
3401 through 3403. Such report shall include recommendations on the need, if
any, to adjust reimbursement for Medicare payments under subsection (a).</text>
</subsection></section><section id="idD389DF7B04344872933C4919B6E27770"><enum>3405.</enum><header>Whistleblower
and patient protections</header>
<subsection id="H6AE9AAC9CA0744A0B0D8EE491F76FBC6"><enum>(a)</enum><header>Recognition of
duty and right of nurses To advocate in the exclusive interest of the
patient</header><text>A nurse shall have the right to act as the patient’s
advocate, as circumstances require, by—</text>
<paragraph id="idD93504408EED4C708EC595BDB097714E"><enum>(1)</enum><text>initiating action
to improve health care or to change decisions or activities, including the
recommendations of health information technology tools, which, in the
professional judgment of the nurse, are against the interests and wishes of the
patient; and</text>
</paragraph><paragraph id="id317850585DD14A2097649500BFA66C3D"><enum>(2)</enum><text>giving the
patient an opportunity to make informed decisions about health care before it
is provided.</text>
</paragraph></subsection><subsection id="id1BA58269E26D460B81E3DBE222C5A0DF"><enum>(b)</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="H05921ADD40FD4025A4678E00F1E1C21D"><enum>(1)</enum><text>the assignment
would violate section 3401 or 3403; or</text>
</paragraph><paragraph id="H47BD01D609504CE393CF17403DB4075F"><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="H30307BA79DE442B3AC15D971A8A24D76"><enum>(c)</enum><header>Retaliation for
refusal of assignment barred</header>
<paragraph id="H74C583E3D8A6445B88E4B4EC8B5E82AE"><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 3407(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).</text>
</paragraph><paragraph id="HC47AC80A583341B2A0E443329B7F9404"><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 described in subsection (b).</text>
</paragraph></subsection><subsection id="HCC1897C9FC774196B354FA988E4D46BE"><enum>(d)</enum><header>Cause of
action</header><text>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:</text>
<paragraph id="H51125CFF28A940E499B17B2349B76506"><enum>(1)</enum><text>Reinstatement.</text>
</paragraph><paragraph id="HB601089264D94457AC86B3DFD2387D9F"><enum>(2)</enum><text>Reimbursement of
lost wages, compensation, and benefits.</text>
</paragraph><paragraph id="H9FBEF88F8FBF45B280DE61602E163029"><enum>(3)</enum><text>Attorneys’
fees.</text>
</paragraph><paragraph id="HD1940F4F417545E8BB9FFB4C8D42ABD6"><enum>(4)</enum><text>Court
costs.</text>
</paragraph><paragraph id="H3BD226724B51415D8600B1A2D932D74F"><enum>(5)</enum><text>Other
damages.</text>
</paragraph></subsection><subsection id="HB0BB284491494FE3009C41B3B5F002C"><enum>(e)</enum><header>Complaint to
Secretary</header>
<paragraph id="id56B8AB550F774057BF9E1DDF9861574A"><enum>(1)</enum><header>In
general</header><text>A nurse, patient, or other individual may file a
complaint with the Secretary against a hospital that violates the provisions of
this title. For any complaint filed, the Secretary shall—</text>
<subparagraph id="HC92A4F0089A54BD588B619C04CAFDDA6"><enum>(A)</enum><text>receive and
investigate the complaint;</text>
</subparagraph><subparagraph id="H46CEE34A6F4D40B99EDF1139E720C2D"><enum>(B)</enum><text>determine whether a
violation of this title as alleged in the complaint has occurred; and</text>
</subparagraph><subparagraph id="H5E9186A4780641668CC846508CD93536"><enum>(C)</enum><text>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).</text>
</subparagraph></paragraph></subsection><subsection id="id3814181E0027437CACFEEC825C2F57AD"><enum>(f)</enum><header>Toll-Free
telephone number</header>
<paragraph id="idC4EDD038836F4A9AA93E61AE7D3A6807"><enum>(1)</enum><header>In
general</header><text>The Secretary shall provide for the establishment of a
toll-free telephone hotline to provide information regarding the requirements
under section 3401 and to receive reports of violations of such section.</text>
</paragraph><paragraph id="idF7EEE038FDCC45B1B89EDA67BFEBFFFF"><enum>(2)</enum><header>Notice to
patients</header><text>A hospital shall provide each patient admitted to the
hospital for inpatient care with the hotline described in paragraph (1), and
shall give notice to each patient that such hotline may be used to report
inadequate staffing or care.</text>
</paragraph></subsection><subsection id="H0CE286AE3B094E3A80E7A4608DBA65D8"><enum>(g)</enum><header>Protection for
reporting</header>
<paragraph commented="no" id="H222591F33A0543B7AC6255B7A2C8B147"><enum>(1)</enum><header>Prohibition on
retaliation or discrimination</header><text>A hospital shall not discriminate
or retaliate in any manner against any patient, employee, or contract employee
of the hospital, or any other individual, on the basis that such individual, in
good faith, individually or in conjunction with another person or persons, has
presented a grievance or complaint, or has initiated or cooperated in any
investigation or proceeding of any governmental entity, regulatory agency, or
private accreditation body, made a civil claim or demand, or filed an action
relating to the care, services, or conditions of the hospital or of any
affiliated or related facilities.</text>
</paragraph><paragraph id="HE0974129D8FA428881C1B96ECF101739"><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="H20448E0DE54F40AD852443006BC9FD17"><enum>(A)</enum><text>the information
reported or disclosed is true; and</text>
</subparagraph><subparagraph id="H227F23B1BB944A4FA7DDD36F61CDB00"><enum>(B)</enum><text>a violation of this
title has occurred or may occur.</text>
</subparagraph></paragraph></subsection><subsection id="H923F47951FF44B71B287CCA34062B379"><enum>(h)</enum><header>Prohibition on
interference with rights</header>
<paragraph id="id87D16EF7CC0A48F18BE6706EDEDFF5CB"><enum>(1)</enum><header>Exercise of
rights</header><text>It shall be unlawful for any hospital to—</text>
<subparagraph id="idA791E07C5240491DA97861A6B10A3F3F"><enum>(A)</enum><text>interfere with,
restrain, or deny the exercise, or attempt to exercise, by any person of any
right provided or protected under this title; or</text>
</subparagraph><subparagraph id="idF9E8D337FE6F45B69C75253532861057"><enum>(B)</enum><text>coerce or
intimidate any person regarding the exercise or attempt to exercise such
right.</text>
</subparagraph></paragraph><paragraph id="id18933BF6B81040209F3BD5EA47E15AB1"><enum>(2)</enum><header>Opposition to
unlawful policies or practices</header><text>It shall be unlawful for any
hospital to discriminate or retaliate against any person for opposing any
hospital policy, practice, or actions which are alleged to violate, breach, or
fail to comply with any provision of this title.</text>
</paragraph><paragraph id="idBD2E3E8B9B3F4C3E9D244AE62D8911DE"><enum>(3)</enum><header>Prohibition on
interference with protected communications</header><text>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.</text>
</paragraph><paragraph id="id9E8FF7EEFAB34E919D4A936CC33D738E"><enum>(4)</enum><header>Prohibition on
interference with collective action</header><text>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).</text>
</paragraph></subsection><subsection id="id34595BB3332E4BCA8FE9550AAE20D64D"><enum>(i)</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="H9275F5DCB8C646B7A51F5F98DFE46BC4"><enum>(1)</enum><text>explains the
rights of nurses, patients, and other individuals under this section;</text>
</paragraph><paragraph id="HAD1B9235B6DD48FF9F19743DCAC4EB3E"><enum>(2)</enum><text>includes a
statement that a nurse, patient, or other individual may file a complaint with
the Secretary against a hospital that violates the provisions of this title;
and</text>
</paragraph><paragraph id="H0329E37352384CE78D4577197600E34F"><enum>(3)</enum><text>provides
instructions on how to file a complaint under paragraph (2).</text>
</paragraph></subsection><subsection id="H0E1A93A3C01B483C806B4BF23C338621"><enum>(j)</enum><header>Effective
dates</header>
<paragraph id="HA99B9234541047AE8294B43F0033285B"><enum>(1)</enum><header>Refusal;
retaliation; cause of action</header>
<subparagraph id="HDBCB5F048EEE46A5B61FE7E329C300E"><enum>(A)</enum><header>In
general</header><text>Subsections (b) through (d) shall apply to refusals
occurring on or after the effective date of the provision to which the refusal
relates.</text>
</subparagraph><subparagraph id="H9D219ADA230848CB008125B77372292"><enum>(B)</enum><header>Exception</header><text>Subsection
(b)(2) shall not apply to refusals in any hospital before the requirements of
section 3401(a) apply to that hospital.</text>
</subparagraph></paragraph><paragraph id="H8A23FD06129A43A28BEEEF0558C9D3"><enum>(2)</enum><header>Protections for
reporting</header><text>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.</text>
</paragraph><paragraph id="H10CB6F94D16642E9B7005D772DB07EB5"><enum>(3)</enum><header>Notice</header><text>Subsection
(i) shall take effect 18 months after the date of enactment of this
title.</text>
</paragraph></subsection></section><section id="id5327E3B2DD554AC38AF6D7CE29CC74E0"><enum>3406.</enum><header>Enforcement</header>
<subsection id="id7F35D8D656D6444C940B2E6196E28560"><enum>(a)</enum><header>In
general</header><text>The Secretary shall enforce the requirements and
prohibitions of this title in accordance with this section.</text>
</subsection><subsection id="id262A4CFE76B34B0587577ACDE7E2FAEC"><enum>(b)</enum><header>Procedures for
receiving and investigating complaints</header><text>The Secretary shall
establish procedures under which—</text>
<paragraph id="id8E92878FA1C344E6B80840FDFBCA655B"><enum>(1)</enum><text>any person may
file a complaint alleging that a hospital has violated a requirement or a
prohibition of this title; and</text>
</paragraph><paragraph id="idC7EE800C364C48AD9DA2F14A6E715E88"><enum>(2)</enum><text>such complaints
shall be investigated by the Secretary.</text>
</paragraph></subsection><subsection id="idE508B23253924412929098A7D4A7B2F5"><enum>(c)</enum><header>Remedies</header><text>If
the Secretary determines that a hospital has violated a requirement of this
title, the Secretary—</text>
<paragraph id="id0B9BC87260144418814FB3ED49E2152B"><enum>(1)</enum><text>shall require the
facility to establish a corrective action plan to prevent the recurrence of
such violation; and</text>
</paragraph><paragraph id="idE7EF0BC7BE8B49D3B3E0307054E98EE7"><enum>(2)</enum><text>may impose civil
money penalties, as described in subsection (d).</text>
</paragraph></subsection><subsection id="id0BAFBA2435CC48F79869C50AAAF4860B"><enum>(d)</enum><header>Civil
penalties</header>
<paragraph id="id822CCB0E75854DA7A3C94986B9497BB9"><enum>(1)</enum><header>In
general</header><text>In addition to any other penalties prescribed by law, the
Secretary may impose civil penalties as follows:</text>
<subparagraph id="idFCF4D4FFAC594ECB91DAD82BC099A1D7"><enum>(A)</enum><header>Hospital
liability</header><text>The Secretary may impose on a hospital found to be in
violation of this title, a civil money penalty of not more than $25,000 for
each knowing violation of a requirement of this title, except that the
Secretary shall impose a civil money penalty of more than $25,000 for each such
violation in the case of a participating hospital that the Secretary determines
has a pattern or practice of such violations (with the amount of such
additional penalties being determined in accordance with a schedule or
methodology specified in regulations).</text>
</subparagraph><subparagraph id="id7EE7DF1A131A44479DF6EB0895BE494F"><enum>(B)</enum><header>Individual
liability</header><text>The Secretary may impose on an individual who—</text>
<clause id="idB9F136D5E72F475C9C8A78C19E19D2C2"><enum>(i)</enum><text>is employed by a
hospital found by the Secretary to have violated a requirement of this title;
and</text>
</clause><clause id="id5521D986D389477DAC6C20B340474923"><enum>(ii)</enum><text>willfully
violates this title,</text>
</clause><continuation-text continuation-text-level="subparagraph">a civil
money penalty of not more than $20,000 for each such violation.</continuation-text></subparagraph></paragraph><paragraph id="idED47B2674075483EB8AF8D7589E3A78A"><enum>(2)</enum><header>Procedures</header><text>The
provisions of section 1128A of the Social Security Act (other than subsections
(a) and (b)) shall apply to a civil money penalty under this paragraph in the
same manner as such provisions apply to a penalty or proceeding under such
section 1128A.</text>
</paragraph></subsection><subsection id="id206F78374E3C4EC996E6FB64EF9CAF90"><enum>(e)</enum><header>Public notice
of violations</header>
<paragraph id="id62DBDF20CA8C4B54A4FEB18C5C43DCF1"><enum>(1)</enum><header>Internet
website</header><text>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.</text>
</paragraph><paragraph id="idC7E82E90B63C41B4A102377F45B14747"><enum>(2)</enum><header>Change of
ownership</header><text>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.</text>
</paragraph></subsection><subsection id="id95A175E410A84C8C890F23F2905260E9"><enum>(f)</enum><header>Offset</header><text>Funds
collected by the Secretary under this section shall be used to offset the costs
of enforcing this title.</text>
</subsection></section><section id="H6E100D99C4894EFEAEC53C9CBD9BEC22"><enum>3407.</enum><header>Definitions</header><text display-inline="no-display-inline">For purposes of this title:</text>
<paragraph id="H4571E5687E114329A0101DB8CB3C6F45"><enum>(1)</enum><header>Acuity
system</header><text>The term <term>acuity system</term> means an established
measurement tool that—</text>
<subparagraph id="H7B99C82426634724BED829240019D1E"><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="HE539C36B0A4D457600A1561757937D85"><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="HAE922E9C320A4EDD8934A3BE7AB711C"><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="H1E5F8987E590461C90BFFB3C00DE9CB5"><enum>(D)</enum><text>is stated in terms
that can be readily used and understood by nurses.</text>
</subparagraph></paragraph><paragraph id="HEC23EAC1B35A4888900868462DF87057"><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="HAF24D2B1EA2D473FB500E55700B9DDB4"><enum>(3)</enum><header>Direct care
registered nurse</header><text>The term <term>direct care registered
nurse</term> means an individual who has been granted a license by at least 1
State to practice as a registered nurse and who provides bedside care for 1 or
more patients.</text>
</paragraph><paragraph id="H41F19AD6ECD74968A49DF777D4FDFD3E"><enum>(4)</enum><header>Employment</header><text>The
term <term>employment</term> includes the provision of services under a
contract or other arrangement.</text>
</paragraph><paragraph id="H51BA31CB0F4A4A128933E3E35204A9C2"><enum>(5)</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 long-term care hospital, as defined in section 1861(ccc) of such
Act.</text>
</paragraph><paragraph id="H17F5AF64125549DCB4B129024911D8EC"><enum>(6)</enum><header>Nurse</header><text>The
term <term>nurse</term> means any direct care registered nurse or direct care
licensed practical nurse (as the case may be), regardless of whether or not the
nurse is an employee.</text>
</paragraph><paragraph id="H352E49C3D7DD4007BCD1C9F1931557EB"><enum>(7)</enum><header>Staffing
plan</header><text>The term <term>staffing plan</term> means a staffing plan
required under section 3401.</text>
</paragraph><paragraph id="id4D4AAFEA5BC14B11814255D578263B6B"><enum>(8)</enum><header>State of
emergency</header><text>The term <term>state of emergency</term> 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, 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>
</paragraph></section><section id="id29D525D858444EC59EF912EB47AC844C"><enum>3408.</enum><header>Rule of
construction</header><text display-inline="no-display-inline">Nothing in this
title shall be construed to authorize disclosure of private and confidential
patient information, except in the case where such disclosure is otherwise
required by law, compelled by proper legal process, consented to by the
patient, provided in confidence to regulatory or accreditation agencies or
other government entities for investigatory purposes, or provided pursuant to
formal or informal complaints of unlawful or improper practices for purposes of
achieving corrective and remedial
action.</text>
</section>.
(b)Recommendations
to CongressNot later than 1 year after the date of enactment of
this Act, the Secretary of Health and Human Services shall submit to Congress a
report containing recommendations for ensuring that sufficient numbers of
nurses are available to meet the requirements imposed by title XXXIV of the
Public Health Service Act, as added
by subsection (a).
(c)
(1)Not later than 2 years after the date of enactment of
this Act, the Administrator of the Health Resources and Services
Administration, in consultation with the National Health Care Workforce
Commission, shall submit to Congress a report regarding the relationship
between nurse staffing levels and nurse retention in hospitals.
(2)Not later than 5 years after the date of enactment of this
Act, the Administrator of the Health Resources and Services Administration, in
consultation with the National Health Care Workforce Commission, shall submit
to Congress an update of the report submitted under paragraph (1).
3.Enforcement of
requirements through Federal programs
(a)Section 1866(a)(1) of the Social Security Act (42 U.S.C.
1395cc(a)(1)) is amended—
(1)by striking
and
at the end of subparagraph (V);
(2)in subparagraph
(W), as added by section 3005(1)(C) of the Patient Protection and Affordable
Care Act (Public Law 111–148)—
(A)by moving such
subparagraph 2 ems to the left; and
(B)by striking the
period at the end and inserting a comma;
(3)by redesignating
subparagraph (W), as added by section 6406(b)(3) of the Patient Protection and
Affordable Care Act (Public Law 111–148), as subparagraph (X) and moving such
subparagraph 2 ems to the left;
(4)in subparagraph
(X), as redesignated by paragraph (3), by striking the period at the end and
inserting , and
; and
(5)by inserting after
subparagraph (X), as so redesignated, the following:
(Y)in the case of a hospital, to be
subject to the provisions of title XXXIV of the Public Health Service
Act.
.
(b)Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)) is
amended—
(1)in paragraph
(82)(C), by striking and
at the end;
(2)in paragraph
(83), by striking the period at the end and inserting ; and
;
and
(3)by inserting
after paragraph (83) the following new paragraph:
(84)provide that any
hospital receiving payments under such plan shall be subject to the provisions
of title XXXIV of the Public Health Service
Act.
.
4.Nurse Workforce
Initiative
(a)Scholarship and
stipend programSection 846(d) of the Public Health Service Act
(42 U.S.C. 297n(d)) is amended—
(1)in the section
heading, by inserting and
Stipend
after Scholarship
; and
(2)in paragraph (1),
by inserting or stipends
after
scholarships
.
(b)Section 831A(b) of the Public Health Service Act (42
U.S.C. 296p–1(b)) is amended—
(1)by striking
Grants for Career Ladder
Program.—
and inserting Grants for Nurse
Retention.—
;
(2)in paragraph (2),
by striking ; or
and inserting a semicolon;
(3)in paragraph (3),
by striking the period and inserting a semicolon; and
(4)by adding at the
end the following:
(4)to provide
additional support to nurses entering the workforce by implementing nursing
preceptorship projects that establish a period of practical and clinical
experiences and training for nursing students, newly hired nurses, and recent
graduates of a direct care degree programs for registered nurses; or
(5)to implement
mentorship projects that assist new or transitional direct care registered
nurses in adapting to the hospital
setting.
.