[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[S. 739 Introduced in Senate (IS)]

113th CONGRESS
  1st Session
                                 S. 739

    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

                             April 16, 2013

  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 XXXIV--MINIMUM DIRECT CARE REGISTERED NURSE STAFFING 
                              REQUIREMENTS

``SEC. 3401. 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) One patient in trauma emergency units.
                    ``(B) One patient in operating room units, provided 
                that a minimum of 1 additional person serves as a scrub 
                assistant in such unit.
                    ``(C) 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.
                    ``(D) Three patients in emergency room units, 
                stepdown units, pediatrics units, telemetry units, 
                antepartum units, and combined labor, delivery, and 
                postpartum units.
                    ``(E) Four patients in medical-surgical units, 
                intermediate care nursery units, psychiatric units, and 
                other specialty care units.
                    ``(F) Five patients in rehabilitation units, and 
                skilled nursing units.
                    ``(G) Six patients in well-baby nursery units and 
                postpartum (3 couplets) units.
            ``(2) 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 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.
            ``(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.
            ``(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.--
                    ``(A) In general.--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.
                    ``(B) Guidance.--The Secretary shall issue guidance 
                to hospitals that describes situations that constitute 
                a state of emergency for purposes of the exemption 
                under this paragraph.
    ``(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 3407(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 
                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.
                    ``(E) The level and quality 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 transparent 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 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.
    ``(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. 3402. 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 3401;
            ``(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. 3403. 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 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.
    ``(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. 3404. ADJUSTMENT IN REIMBURSEMENT.

    ``(a) Medicare Reimbursement.--The Secretary shall adjust payments 
made to hospitals under title XVIII of the Social Security Act in an 
amount equal to the net amount of additional costs incurred in 
providing services to Medicare beneficiaries that are attributable to 
compliance with requirements imposed under sections 3401 through 3403. 
The amount of such payment adjustments shall take into account 
recommendations contained in the report submitted by the Medicare 
Payment Advisory Commission under subsection (b).
    ``(b) MedPAC Report.--Not later than 2 years after the date of the 
enactment of this title, the Medicare Payment Advisory Commission 
(established under section 1805 of the Social Security Act) shall 
submit to Congress and the Secretary a report estimating total costs 
and savings attributable to compliance with requirements imposed under 
sections 3401 through 3403. Such report shall include recommendations 
on the need, if any, to adjust reimbursement for Medicare payments 
under subsection (a).

``SEC. 3405. 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, 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
            ``(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 3401 or 3403; 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 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).
            ``(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 3401 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 3401(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. 3406. 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 section 
shall be used to offset the costs of enforcing this title.

``SEC. 3407. 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) 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.
            ``(4) Employment.--The term `employment' includes the 
        provision of services under a contract or other arrangement.
            ``(5) Hospital.--The term `hospital' has the meaning given 
        that term in section 1861(e) of the Social Security Act and 
        includes a hospital that is operated by the Department of 
        Veterans Affairs and a long-term care hospital (as defined in 
        section 1861(ccc) of such Act).
            ``(6) 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.
            ``(7) Staffing plan.--The term `staffing plan' means a 
        staffing plan required under section 3401.
            ``(8) State of emergency.--The term `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, 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. 3408. 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 XXXIV of the Public Health Service 
Act, as added by subsection (a).
    (c) Report by HRSA.--
            (1) In general.--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) Updated report.--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).

SEC. 3. ENFORCEMENT OF REQUIREMENTS THROUGH FEDERAL PROGRAMS.

    (a) Medicare Program.--Section 1866(a)(1) of the Social Security 
Act (42 U.S.C. 1395cc(a)(1)) is amended--
            (1) by striking ``and'' at the end of subparagraph (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) Medicaid Program.--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.''.
    (c) Health Benefits Program of the Department of Veterans 
Affairs.--Section 8110(a) of title 38, United States Code, is amended 
by adding at the end the following:
            ``(7) Subject to appropriations, the Secretary of Veterans 
        Affairs may require that a Department medical facility that is 
        a hospital shall comply with the provisions of title XXXIV of 
        the Public Health Service Act.
            ``(8) Nothing either in chapter 74 of this title or in 
        section 7106 of title 5 shall preclude enforcement of the 
        provisions of title XXXIV of the Public Health Service Act with 
        respect to a Department hospital through grievance procedures 
        negotiated in accordance with chapter 71 of title 5.''.
    (d) Authorization of Appropriations.--There are authorized to be 
appropriated to the Secretary of Veterans Affairs, for compliance with 
title XXXIV of the Public Health Service Act pursuant to section 
8110(a)(7) of title 38, United States Code, such sums as may be 
necessary for fiscal year 2014 and each subsequent fiscal year.

SEC. 4. NURSE WORKFORCE INITIATIVE.

    (a) Scholarship and Stipend Program.--Section 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) Nurse Retention Grants.--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.''.
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