<enum>XXXIV</enum><header>MINIMUM DIRECT CARE REGISTERED NURSE STAFFING REQUIREMENT</header><section id="HFC925ECB5E4D4ED7AC8EE149E9E4966F"><enum>3401.</enum><header>Minimum nurse staffing requirement</header><subsection id="H348D8F341C5348009AE571C6910B80CC"><enum>(a)</enum><header>Staffing plan</header><paragraph id="H1796C8EB817444FE95908B47F80013C4"><enum>(1)</enum><header>In general</header><text>A hospital shall implement a staffing plan that—</text><subparagraph id="H098F420D99A946F1ADBADC024515CE22"><enum>(A)</enum><text>provides adequate, appropriate, and quality delivery of health care services and protects patient safety; and</text></subparagraph><subparagraph id="H6DD4723A0085486EBE9EE40A9748E39A"><enum>(B)</enum><text>is consistent with the requirements of this title.</text></subparagraph></paragraph><paragraph id="H83699A71D56C45D797120D42F7EDF07E"><enum>(2)</enum><header>Effective dates</header><subparagraph id="H7C2FEA5B509049C9B8F43BE92DA7839F"><enum>(A)</enum><header>Implementation of staffing plan</header><text>Subject to subparagraph (B), the requirements under paragraph (1) shall take effect on a date to be determined by the Secretary, but not later than 1 year after the date of the enactment of this title.</text></subparagraph><subparagraph id="H13428ECA959F456D8C98E7C265F90833"><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—</text><clause id="H6FA943EF0F7446E9A5ECF33137E91D5A"><enum>(i)</enum><text>2 years after the date of enactment of this title; and</text></clause><clause id="H8D89105E1211445C94181875AA828656"><enum>(ii)</enum><text>in the case of a hospital in a rural area (as defined in section 1886(d)(2)(D) of the Social Security Act), 4 years after the date of enactment of this title.</text></clause></subparagraph></paragraph></subsection><subsection id="H1E307B155EE942C6AE5DEAB3F1A8F1AE"><enum>(b)</enum><header>Minimum direct care registered nurse-to-Patient ratios</header><paragraph id="H53FD0563B3CF48F3AAE97173D6FD792D"><enum>(1)</enum><header>In general</header><text>Except as provided in paragraph (4) and other provisions of this section, a hospital’s staffing plan shall provide that, at all times during each shift within a unit of the hospital, and with a full complement of ancillary and support staff, a direct care registered nurse may be assigned to not more than the following number of patients in that unit:</text><subparagraph id="H769E18F1C8214985B648D5955D82E85F"><enum>(A)</enum><text>One patient in trauma emergency units.</text></subparagraph><subparagraph id="H08A92451BA86455689D6818F2CFC0D4C"><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="HDCD4826D33B24458A4EC46094B0A3E8F"><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="H8F48DAE0CCD14617B987CEAEDDA6CCBC"><enum>(D)</enum><text>Three patients in emergency room units, pediatrics units, stepdown units, telemetry units, antepartum units, and combined labor, deliver, and postpartum units.</text></subparagraph><subparagraph id="H4CAA161D86D94103B5483C083E8FD56F"><enum>(E)</enum><text>Four patients in medical-surgical units, intermediate care nursery units, acute care psychiatric units, and other specialty care units.</text></subparagraph><subparagraph id="HC33E6865BD014E058F20B3303E4B789D"><enum>(F)</enum><text>Five patients in rehabilitation units and skilled nursing units.</text></subparagraph><subparagraph id="H0461A8E6E1FE4752B01528E024598CEE"><enum>(G)</enum><text>Six patients in postpartum (3 couplets) units and well-baby nursery units.</text></subparagraph></paragraph><paragraph id="H7BD4CCC1E47B42D7A2E8308D4246E75D"><enum>(2)</enum><header>Similar units with different names</header><text>The Secretary may apply minimum direct care registered nurse-to-patient ratios established in paragraph (1) for a hospital unit referred to in such paragraph to a type of hospital unit not referred to in such paragraph if such type of hospital unit provides a level of care to patients whose needs are similar to the needs of patients cared for in the hospital unit referred to in such paragraph.</text></paragraph><paragraph id="H99B863D2F6BA498EA62EBAA9B6D5D9AB"><enum>(3)</enum><header>Application of ratios to hospital nursing practice standards</header><subparagraph id="H75A86383C5C040AF8E2B6719584DE61F"><enum>(A)</enum><header>In general</header><text>A patient assignment may be included in the calculation of the direct care registered nurse-to-patient ratios required in this subsection only if care is provided by a direct care registered nurse and the provision of care to the particular patient is within that direct care registered nurse’s competence.</text></subparagraph><subparagraph id="H0E8858BC75474EAAA3349928AB95C442"><enum>(B)</enum><header>Demonstration of unit-specific competence</header><text>A hospital shall not assign a direct care registered nurse to a hospital unit unless that hospital determines that the direct care registered nurse has demonstrated current competence in providing care in that unit, and has also received orientation to that hospital’s unit sufficient to provide competent care to patients in that unit.</text></subparagraph><subparagraph id="H0B6A92BED23340D2B4FAF3DD752BB763"><enum>(C)</enum><header>Duties of the assigned direct care registered nurse</header><text>Each patient shall be assigned to a direct care registered nurse who shall directly provide the assessment, planning, supervision, implementation, and evaluation of the nursing care provided to the patient at least every shift and has the responsibility for the provision of care to a particular patient within his or her scope of practice.</text></subparagraph><subparagraph id="H5814ACFF259E464682703E4277C30E34"><enum>(D)</enum><header>Nurse administrators and supervisors</header><text>A registered nurse who is a nurse administrator, nurse supervisor, nurse manager, charge nurse, case manager, or any other hospital administrator or supervisor, shall not be included in the calculation of the direct care registered nurse-to-patient ratio unless that nurse has a current and active direct patient care assignment and provides direct patient care in compliance with the requirements of this section, including competency requirements. The exemption in this subsection shall apply only during the hours in which the individual registered nurse has the principal responsibility of providing direct patient care and has no additional job duties as would a direct care registered nurse.</text></subparagraph><subparagraph id="H4801D5A7312E4DA285720230ED711743"><enum>(E)</enum><header>Other personnel</header><text>Other personnel may perform patient care tasks based on their training and demonstrated skill but may not perform or assist in direct care registered nurse functions unless authorized to do in accordance with State scope of practice laws and regulations.</text></subparagraph><subparagraph id="H056793C81A3C41719C09E0BF6028B0E3"><enum>(F)</enum><header>Temporary nursing personnel</header><text>A hospital shall not assign any nursing personnel from temporary nursing agencies patient care to any hospital unit without such personnel having demonstrated competence on the assigned unit and received orientation to that hospital’s unit sufficient to provide competent care to patients in that unit.</text></subparagraph><subparagraph id="H341F04DCCDAE4D1CB67CCEDE43E658BE"><enum>(G)</enum><header>Ancillary and additional staffing</header><text>The need for additional staffing of direct care registered nurses, licensed vocational or practical nurses, licensed psychiatric technicians, certified nursing or patient care assistants, or other licensed or unlicensed ancillary staff above the minimum registered nurse-to-patient ratios shall be based on the assessment of the individual patient’s nursing care requirement, the individual patient’s nursing care plan, and acuity level.</text></subparagraph></paragraph><paragraph id="HEC07952AF6B14AB3B97CA0E9550A9D61"><enum>(4)</enum><header>Restrictions</header><subparagraph id="H7417C983EC124986867F37862EB26E23"><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="HFA49CDCAEFBA4091A0C3BF8B280315BE"><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="H0D0F0C05742B4A848AB5B9F7296C12DD"><enum>(C)</enum><header>Relief during routine absences</header><text>A hospital shall ensure that only a direct care registered nurse who has demonstrated current competence to the hospital in providing care on a particular unit and has also received orientation to that hospital’s unit sufficient to provide competent care to patients in that unit may relieve another direct care registered nurse during breaks, meals, and other routine, expected absences from a hospital unit.</text></subparagraph><subparagraph id="HD377D82BDE234812B72B5E399BA34BBB"><enum>(D)</enum><header>Application of direct care registered nurse-to-patient ratios in patient-acuity adjustable units</header><text>Patients shall be cared for only on units or patient care areas where the direct care registered nurse-to-patient ratios meet the level of intensity, type of care, and the individual requirements and needs of each patient. Notwithstanding paragraph (2), hospitals that provide patient care in units or patient care areas that are acuity adaptable or acuity adjustable shall apply the direct care registered nurse-to-patient ratio required in this section for the highest patient acuity level or level of care in that unit or patient care area, and shall comply with all other requirements of this section.</text></subparagraph><subparagraph id="H8F153F9AD93846D984FE277F5AA6EB27"><enum>(E)</enum><header>Use of video monitors</header><text>A hospital shall not employ video monitors or any form of electronic visualization of a patient as a substitute for the direct observation required for patient assessment by the direct care registered nurse or required for patient protection. Video monitors or any form of electronic visualization of a patient shall not be included in the calculation of the direct care registered nurse-to-patient ratio required in this subsection and shall not replace the requirement of paragraph (3)(D) that each patient shall be assigned to a direct care registered nurse who shall directly provide the assessment, planning, supervision, implementation, and evaluation of the nursing care provided to the patient at least every shift and have the responsibility for the provision of care to a particular patient within his or her scope of practice.</text></subparagraph><subparagraph id="H9C9C81D10C7B4C18BB9E851BA24507BA"><enum>(F)</enum><header>Use of other technology</header><text>A hospital shall not employ technology that substitutes for the assigned registered nurse’s professional judgment in assessment, planning, implementation, and evaluation of care.</text></subparagraph></paragraph><paragraph id="H301C277B6C7441C69184F1476A5C79DF"><enum>(5)</enum><header>Adjustment of ratios</header><subparagraph id="H7BA40AFF108B48AAAB9A284309AD4FB1"><enum>(A)</enum><header>In general</header><text>If necessary to protect patient safety, the Secretary may prescribe regulations that—</text><clause id="HCC801F550D50424D9560DB43528C8733"><enum>(i)</enum><text>increase minimum direct care registered nurse-to-patient ratios under this subsection to reduce the number of patients that may be assigned to each direct care nurse; or</text></clause><clause id="H299A8AD7057448F8A184A5B167C3BDDB"><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="HB91D863490504E3FACB8B7AC005EEF81"><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="H3623D9F470AD4C85B7CDECAC0E432C74"><enum>(6)</enum><header>Ancillary and additional staffing</header><subparagraph id="HE64CEF5F2FE24730A9DA63DF0805282E"><enum>(A)</enum><header>In general</header><text>The Secretary may prescribe regulations requiring additional staffing of direct care registered nurses, licensed vocational or practice nurses, licensed psychiatric technicians, certified nursing or patient care assistants, or other licensed or unlicensed ancillary staff above the minimum registered nurse-to-patient ratios that is based on the assessment of the individual patient’s nursing care needs, the individual patient’s nursing care plan, and acuity level.</text></subparagraph><subparagraph id="H1ECCC1A10A844DDD81BFF44D16E4EBD2"><enum>(B)</enum><header>Consultation</header><text>Such regulations shall be prescribed after consultation with affected hospitals, registered nurses, and ancillary staff.</text></subparagraph></paragraph><paragraph id="HC740A900AA644BB9B4428BAAC276573C"><enum>(7)</enum><header>Relationship to state-imposed ratios</header><text>Nothing in this title shall preempt State standards that the Secretary determines to be as stringent as 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 as stringent as to Federal requirements for direct care registered nurse-to-patient ratios established under this title.</text></paragraph><paragraph id="HD75D9A79AAC140F7A6EF6E8C34BCECB6"><enum>(8)</enum><header>Exemption in emergencies</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. If a hospital seeks to apply the exemption under this paragraph in response to a complaint filed against the hospital for a violation of the provisions of this title, the hospital must demonstrate that prompt and diligent efforts were made to maintain required staffing levels. The Secretary shall issue guidance to hospitals that describes situations that constitute a state of emergency for purposes of the exemption under this paragraph and shall establish necessary penalties for violations of this paragraph consistent with section 3406.</text></paragraph></subsection><subsection id="HC0E2A388F3F84A348CFC39963B5F03C3"><enum>(c)</enum><header>Development and reevaluation of staffing plan</header><paragraph id="HC886AC7EEDD74FC1BFF9C7B22CDCA9D7"><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, at minimum, the following factors:</text><subparagraph id="HAE9E051C1D9D4141B1254850D9DEBC53"><enum>(A)</enum><text>The number of patients on a particular unit on a shift-by-shift basis.</text></subparagraph><subparagraph id="H87B9BDD080D84BE58B28B7AAA39E3866"><enum>(B)</enum><text>The acuity level and nursing care plan of patients on a particular unit on a shift-by-shift basis.</text></subparagraph><subparagraph id="H1EA6D022373F44AFA66D0A81616D888B"><enum>(C)</enum><text>The anticipated admissions, discharges, and transfers of patients during each shift that impacts direct patient care.</text></subparagraph><subparagraph id="H2C9C0672E0C245768329D6D8D173209B"><enum>(D)</enum><text>Specialized experience required of direct care registered nurses on a particular unit.</text></subparagraph><subparagraph id="HA59E9B8329FD4855AAD2F6FED45637F7"><enum>(E)</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="H298FEC14D9154CACB3D45A0FEE064D30"><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="H4734748567AE4C1E954766EBCDE74118"><enum>(G)</enum><text>Obstacles to efficiency in the delivery of patient care presented by physical layout.</text></subparagraph></paragraph><paragraph id="H03D2CC17F053404CBF67C8BC73D3885A"><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="H2BD23AC1CCCB4328AD7ACBF7F2128AFB"><enum>(3)</enum><header>Annual reevaluation of plan</header><subparagraph id="HC269BF5DF5B64D27BD0EA5B8E3D2270C"><enum>(A)</enum><header>In general</header><text>A hospital shall annually evaluate its staffing plan in each unit in relation to actual patient care requirements.</text></subparagraph><subparagraph id="HD02676175657427B9DB4A6BE8E999F9D"><enum>(B)</enum><header>Update</header><text>A hospital shall update its staffing plan to the extent appropriate based on such evaluation.</text></subparagraph></paragraph><paragraph id="H4E140B3C34494059A234D3D2483C01D3"><enum>(4)</enum><header>Transparency</header><subparagraph id="H9651B54B76C04718BF3B09907FF3D3CE"><enum>(A)</enum><header>In general</header><text display-inline="yes-display-inline">Any staffing plan or method used to create and evaluate acuity-level and adopted by a hospital under this section shall be transparent in all respects, including disclosure of detailed documentation of the methodology used to determine nursing staffing, identifying each factor, assumption, and value used in applying such methodology.</text></subparagraph><subparagraph id="H7C5838E0242640FCBB231B5B4CAB786D"><enum>(B)</enum><header>Public availability</header><text>The Secretary shall establish procedures to provide that the documentation submitted under subsection (d) is available for public inspection in its entirety.</text></subparagraph></paragraph><paragraph id="HB63AA8CAEBF345F89833DD870447B87A"><enum>(5)</enum><header>Registered nurse participation</header><text display-inline="yes-display-inline">A staffing plan of a hospital—</text><subparagraph id="H4BDB27DB0C1145C8A57DE2C998B104FC"><enum>(A)</enum><text>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 from each unit or patient care area; and</text></subparagraph><subparagraph id="H35055687357644B5AABF7A32EC5F37AA"><enum>(B)</enum><text>where such nurses are represented through collective bargaining, shall require bargaining with the applicable recognized or certified collective bargaining representative of such nurses.</text></subparagraph><continuation-text continuation-text-level="paragraph">Nothing in this title shall be construed to permit conduct prohibited under the National Labor Relations Act (<external-xref legal-doc="usc" parsable-cite="usc/29/151">29 U.S.C. 151</external-xref> et seq.) or <external-xref legal-doc="usc-chapter" parsable-cite="usc-chapter/5/71">chapter 71</external-xref> of title 5, United States Code.</continuation-text></paragraph><paragraph id="HC63AE5BC6A614D12978EF77221645C76"><enum>(6)</enum><header>Staffing committees</header><text>If a hospital maintains a staffing committee, then the committee shall include at least one registered nurse from each hospital unit and shall be composed of at least 50 percent direct care registered nurses. The staffing committee shall include meaningful representation of other direct care nonmanagement staff. Direct care registered nurses who serve on the committee shall be selected by other direct care registered nurses from their unit. Other direct care nonmanagement staff shall be selected by other direct care nonmanagement staff. Participation on staffing committees shall be considered a part of the employee’s regularly scheduled workweek.</text></paragraph></subsection><subsection id="HAE030117ABFD4481A0C4CB5B2E979BD7"><enum>(d)</enum><header>Submission of plan to secretary</header><text>A hospital shall submit to the Secretary its staffing plan and any annual updates under subsection (c)(3)(B). A federally operated hospital may submit its staffing plan through the department or agency operating the hospital.</text></subsection></section><section id="HF08F4293B7324A8A81A74AED522BBD9E"><enum>3402.</enum><header>Posting, records, and audits</header><subsection id="H56DF5990F0834973958A7670B077D10C"><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="HDCBE01287538452983DBBA6237ED8B08"><enum>(1)</enum><text>explains requirements imposed under section 3401;</text></paragraph><paragraph id="H472D5B815287480CA4430644DD7E618E"><enum>(2)</enum><text>includes actual direct care registered nurse-to-patient ratios during each shift;</text></paragraph><paragraph id="HEA827D0D9E4A4A2A8DD22FCBBCE89E33"><enum>(3)</enum><text>includes the actual number and titles of direct care registered nurses assigned during each shift; and</text></paragraph><paragraph id="H5DA0563A249344F29092D9314B6C222A"><enum>(4)</enum><text>is visible, conspicuous, and accessible to staff, patients, and the public.</text></paragraph></subsection><subsection id="HF4D1171A02F8436F97C1208139438283"><enum>(b)</enum><header>Records</header><paragraph id="HE8799AA6F197464EB7FCEBEF85DDDF0D"><enum>(1)</enum><header>Maintenance of records</header><text>Each hospital shall maintain accurate records of actual direct care registered nurse-to-patient ratios in each unit for each shift for no less than 3 years. Such records shall include—</text><subparagraph id="H4B68217B075C4E66A39A02AEB484D702"><enum>(A)</enum><text>the number of patients in each unit;</text></subparagraph><subparagraph id="H68B3AA5E5B004EB282D0887D745E38FE"><enum>(B)</enum><text display-inline="yes-display-inline">the identity and duty hours of—</text><clause id="HC382C99AD0194B7AA1639A68B4029DD1"><enum>(i)</enum><text>each direct care registered nurse assigned to each patient in each unit in each shift; and</text></clause><clause id="HC5F6B5FD7DE045808F71747660F732BC"><enum>(ii)</enum><text>ancillary staff who are under the coordination of the direct care registered nurse;</text></clause></subparagraph><subparagraph id="H501F36D1E5464AEFA5ECAD2354CEBB5D"><enum>(C)</enum><text>certification that each nurse received rest and meal breaks and the identity and duty hours of each direct care registered nurse who provided such relief; and</text></subparagraph><subparagraph id="H2657213588E340289B48E231B404B362"><enum>(D)</enum><text>a copy of each notice posted under subsection (a).</text></subparagraph></paragraph><paragraph id="HD5FD47FADAFE44BF94EB8E33C7D238C4"><enum>(2)</enum><header>Availability of records</header><text>Each hospital shall make its records maintained under paragraph (1) available to—</text><subparagraph id="H8970D8BAB33C4353B76D86DC3F04E389"><enum>(A)</enum><text>the Secretary;</text></subparagraph><subparagraph id="H4EE31845BC5D4271AA2C1BF4AD92C949"><enum>(B)</enum><text>registered nurses and their collective bargaining representatives (if any); and</text></subparagraph><subparagraph display-inline="no-display-inline" id="HE9D3F10EAB6C484FB49AE2B820D6AEDA"><enum>(C)</enum><text>the public under regulations established by the Secretary, or in the case of a federally operated hospital, under section 552 of title 5, United States Code (commonly known as the Freedom of Information Act).</text></subparagraph></paragraph></subsection><subsection id="H9312723CA7A24F279BFEB3E33432B74B"><enum>(c)</enum><header>Audits</header><text>The Secretary shall conduct periodic audits to ensure—</text><paragraph id="H4B6E895F3CEE4C638A3A892CE5DF8517"><enum>(1)</enum><text>implementation of the staffing plan in accordance with this title; and</text></paragraph><paragraph id="HC86002F40CC64AF382AAA19B585B71B3"><enum>(2)</enum><text>accuracy in records maintained under this section.</text></paragraph></subsection></section><section id="HC01C3605AB6447C695E4898B8A987AF4"><enum>3403.</enum><header>Minimum direct care licensed practical nurse staffing requirements</header><subsection id="H193E4A0777D84C59A6E5B61A018BB2D7"><enum>(a)</enum><header>Establishment</header><text>A hospital’s staffing plan shall comply with minimum direct care licensed practical nurse staffing requirements that the Secretary establishes for units in hospitals. Such staffing requirements shall be established not later than 18 months after the date of the enactment of this title, and shall be based on the study conducted under subsection (b).</text></subsection><subsection id="HE5582F70A8EE49BA971F076B56670745"><enum>(b)</enum><header>Study</header><text>Not later than 1 year after the date of the enactment of this title, the Secretary, acting through the Director of the Agency for Healthcare Research and Quality, shall complete a study of licensed practical nurse staffing and its effects on patient care in hospitals. The Director may contract with a qualified entity or organization to carry out such study under this paragraph. The Director shall consult with licensed practical nurses and organizations representing licensed practical nurses regarding the design and conduct of the study.</text></subsection><subsection id="HDBD1D28DFC52469C8CBA99335B297A88"><enum>(c)</enum><header>Application of registered nurse provisions to licensed practical nurse staffing requirements</header><text>Paragraphs (2), (4)(A), (4)(B), (4)(C), and (6) of section 3401(b), paragraphs (1), (2), (3), and (4) of section 3401(c), and section 3402 shall apply to the establishment and application of direct care licensed practical nurse staffing requirements under this section pursuant to the additional staffing requirements under subsection (b)(3)(G) of section 3401 and 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="HB072BAD805964AC08BB98BB49D345A81"><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—</text><paragraph id="H8481CE44B7D94D57A152E8B4F95722BB"><enum>(1)</enum><text>2 years after the date of the enactment of this title; and</text></paragraph><paragraph id="HB1CAA377DD5B4D3FB9D9F2E62A9317E8"><enum>(2)</enum><text>in the case of a hospital in a rural area (as defined in section 1886(d)(2)(D) of the Social Security Act), 4 years after the date of the enactment of this title.</text></paragraph></subsection><subsection id="HB7189F3A35C1409DA02451938CB697AF"><enum>(e)</enum><header>Study</header><text>Not later than 1 year after the date of the enactment of this title, the Secretary, acting through the Director of the Agency for Healthcare Research and Quality shall complete a study of registered and practical nurse staffing requirements in clinics and other outpatient settings, and its effects on patient care in outpatient settings. The Director may contract with a qualified entity or organization to carry out such study under this subsection. The Director shall consult with registered nurses and licensed practice nurses working in outpatient settings, including professional nursing associations and labor organizations representing both registered and practice nurses working in outpatient settings regarding the design and conduct of the study.</text></subsection></section><section id="H29B6BDE03591482EA6A56CB99E9D6D19"><enum>3404.</enum><header>Adjustment in reimbursement</header><subsection id="H13BFB165DBC44A2BB338F63368D5ADC1"><enum>(a)</enum><header>Medicare reimbursement</header><text>The Secretary shall adjust payments made to hospitals (other than federally operated hospitals) under title XVIII of the 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 (c).</text></subsection><subsection id="H073DD0F6497E4FF5A2523A328C161913"><enum>(b)</enum><header>Authorization of appropriation for federally operated hospitals</header><text>There are authorized to be appropriated such additional sums as are required for federally operated hospitals to comply with the additional requirements established under sections 3401 through 3403.</text></subsection><subsection id="H08EEF768F2AD4F83AE414178E517B16F"><enum>(c)</enum><header>MedPAC report</header><text>Not later than 2 years after the date of the enactment of this title, the Medicare Payment Advisory Commission (established under section 1805 of the 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).</text></subsection></section><section id="H26D5CE040FDE44C1BE05D47D2138636B"><enum>3405.</enum><header>Whistleblower and patient protections</header><subsection id="HEDA22026466E41E9AC5BDB7F2B1D4837"><enum>(a)</enum><header>Professional obligation and rights</header><text>All nurses have a duty and right to act based on their professional judgment in accordance with State nursing laws and regulations of the State in which the direct nursing care is being performed and to provide care in the exclusive interests of the patients and to act as the patient’s advocate.</text></subsection><subsection id="H6949E3F89E3340D99145513F7047A0BA"><enum>(b)</enum><header>Acceptance of patient care assignments</header><text>The nurse is responsible for providing competent, safe, therapeutic, and effective nursing care to assigned patients. Before accepting a patient assignment, a nurse shall—</text><paragraph id="H0EAF52F6E2404C20A2C02B50796E54CB"><enum>(1)</enum><text>have the necessary professional knowledge, judgment, skills, and ability to provide the required care;</text></paragraph><paragraph id="HBBD2B98B20BC4AF09FF88C1C2EF78B38"><enum>(2)</enum><text>determine using professional judgment in accordance with State nursing laws and regulations of the State in which the direct nursing care is being performed whether the nurse is competent to perform the nursing care required; and</text></paragraph><paragraph id="H66EFC75BBF424CD19ADC59093C418A2E"><enum>(3)</enum><text>determine whether acceptance of a patient assignment would expose the patient or nurse to risk of harm.</text></paragraph></subsection><subsection id="HFB72A42AC91642D59228FF711317BF8B"><enum>(c)</enum><header>Objection to or refusal of assignment</header><text>A nurse may object to, or refuse to participate in, any activity, policy, practice, assignment, or task if in good faith—</text><paragraph id="H91FD6E700C544A23A87C49E3FF31E677"><enum>(1)</enum><text>the nurse reasonably believes it to be in violation of section 3401 or 3403; or</text></paragraph><paragraph id="H7F79407A4DAE4D2C844C0B280DC510A2"><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="H6A73EFA6472048CBA3C9A17F8182E129"><enum>(d)</enum><header>Retaliation for objection to or refusal of assignment barred</header><paragraph id="HCA0674A7877042D2B3DBADA5920BC6E6"><enum>(1)</enum><header>No discharge, discrimination, or retaliation</header><text>No hospital shall discharge, retaliate, discriminate, or otherwise take adverse action in any manner with respect to any aspect of a nurse’s employment (as defined in section 3407), including discharge, promotion, compensation, or terms, conditions, or privileges of employment, based on the nurse’s refusal of a work assignment under subsection (c).</text></paragraph><paragraph id="H22E2188459944F93ABEEB95FD0B21C35"><enum>(2)</enum><header>No filing of complaint</header><text>No hospital shall file a complaint or a report against a nurse with a State professional disciplinary agency because of the nurse’s refusal of a work assignment under subsection (c).</text></paragraph></subsection><subsection id="H461A8946AD4F4F689F96391B5B87A2B9"><enum>(e)</enum><header>Cause of action</header><text>Any nurse, collective bargaining representative, or legal representative of any nurse who has been discharged, discriminated against, or retaliated against in violation of subsection (d)(1) or against whom a complaint or report has been filed in violation of subsection (d)(2) may (without regard to whether a complaint has been filed under subsection (f) of this section or subsection (b) of section 3406) 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="H708871A500D54B23A31AE6E841BE2AF8"><enum>(1)</enum><text>Reinstatement.</text></paragraph><paragraph id="H2A336F25394E45D19602C06D97578CF9"><enum>(2)</enum><text>Reimbursement of lost wages, compensation, and benefits.</text></paragraph><paragraph id="HCB8E82109234460C974AC1BE8FE06A34"><enum>(3)</enum><text>Attorneys’ fees.</text></paragraph><paragraph id="HFA192BF2F9AD4C67AC6C66C679315305"><enum>(4)</enum><text>Court costs.</text></paragraph><paragraph id="H7D11F78672F74FF2A6FC4D596B67BDF9"><enum>(5)</enum><text>Other damages.</text></paragraph></subsection><subsection id="H372191BE67374366B62524495BE85685"><enum>(f)</enum><header>Complaint to secretary</header><text>A nurse, patient, collective bargaining representative, or other individual may file a complaint with the Secretary against a hospital that violates the provisions of this title. For any complaint filed, the Secretary shall—</text><paragraph id="H89AA91115FC540279A4066C72003B598"><enum>(1)</enum><text>receive and investigate the complaint;</text></paragraph><paragraph id="H6CE13199B3E645A780EDFAA03255CA2F"><enum>(2)</enum><text>determine whether a violation of this title as alleged in the complaint has occurred; and</text></paragraph><paragraph id="HAD44C3F298824134A3109F3F3E8879F5"><enum>(3)</enum><text>if such a violation has occurred, issue an order that the complaining nurse or individual shall not suffer any discharge, retaliation, discrimination, or other adverse action prohibited by subsection (d) or subsection (h).</text></paragraph></subsection><subsection id="HA139D615A6284138AB485948300F311C"><enum>(g)</enum><header>Toll-Free telephone number</header><paragraph id="H066D25314BF04AFB99A98C6A77F224B6"><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 through 3403 and to receive reports of violations of such section.</text></paragraph><paragraph id="H137002BE44904F97AC085A79FE1AB911"><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="H7478EF3287C84070A7BEA29475944FD3"><enum>(h)</enum><header>Protection for reporting</header><paragraph id="H0B44F391DF5E49CAB72E63CE7B9C686D"><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="HD4992962C24A4721B7A6CBAB307224CD"><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="H3B5B485ACF314B04A8B24864D7C2877C"><enum>(A)</enum><text>the information reported or disclosed is true; and</text></subparagraph><subparagraph id="H350D2A2E1BED4EAABFB49AFAC88C5A92"><enum>(B)</enum><text>a violation of this title has occurred or may occur.</text></subparagraph></paragraph></subsection><subsection id="HD4DB28B1FEF44C44BB7786ADC3B5FAD0"><enum>(i)</enum><header>Prohibition on interference with rights</header><paragraph id="H5DB670C3A50047F9A63C65A434D46037"><enum>(1)</enum><header>Exercise of rights</header><text>It shall be unlawful for any hospital to—</text><subparagraph id="HF6069FDF47DC42DCBB42A9EF35D44CD2"><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="HE8CDA7194E754780943F5C3E2F809361"><enum>(B)</enum><text>coerce or intimidate any person regarding the exercise or attempt to exercise such right.</text></subparagraph></paragraph><paragraph id="HD0CFCE918BA44B4B8A8FEC06A0D7D7EB"><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="HD9C1CC8972374E42BAF7B18D4E46F408"><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 nurse from, or intimidates, coerces, or induces a direct care nurse regarding, engaging in free speech activities or disclosing information as provided under this title.</text></paragraph><paragraph id="H9E9958E17F7C465FBEA72DF199B787D6"><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 (<external-xref legal-doc="usc" parsable-cite="usc/29/157">29 U.S.C. 157</external-xref>).</text></paragraph></subsection><subsection id="H411A8CFAF220407D8A3CEE9B736F0254"><enum>(j)</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="HF31DD065B7BB444B86773F0030742913"><enum>(1)</enum><text>explains the rights of nurses, patients, and other individuals under this section;</text></paragraph><paragraph id="HD501A64CD59E4E4CB581DA476F10D044"><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="HE58241BF965F41D98FCAF6CE90726DF4"><enum>(3)</enum><text>provides instructions on how to file such a complaint.</text></paragraph></subsection><subsection id="H0998B883BAF04ED0AA42B7992403FDEF"><enum>(k)</enum><header>Effective date</header><paragraph id="H07FB47FEEF9746DD89AC0DE7C7256BC7"><enum>(1)</enum><header>Refusal; retaliation; cause of action</header><subparagraph id="HC236101C259E409B84AB870492087DD6"><enum>(A)</enum><header>In general</header><text>Subsections (c) through (e) shall apply to objections and refusals occurring on or after the effective date of the provision of this title to which the objection or refusal relates.</text></subparagraph><subparagraph id="H8D8683A7DF214B2EAE1423F8BFFB02EF"><enum>(B)</enum><header>Exception</header><text>Subsection (c)(2) shall not apply to objections or refusals in any hospital before the requirements of section 3401(a) or 3403(a), as applicable, apply to that hospital.</text></subparagraph></paragraph><paragraph id="H6CBB9D5187CA4816A682B48B1B82EBAC"><enum>(2)</enum><header>Protections for reporting</header><text>Subsection (h)(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="H68F547E19D0347698C0475E1D857E4A9"><enum>(3)</enum><header>Notice</header><text>Subsection (j) shall take effect 18 months after the date of enactment of this title.</text></paragraph></subsection></section><section id="H64EF461C27564B07ACE283D4B5E96616"><enum>3406.</enum><header>Enforcement</header><subsection id="HFD3479EFCA0841B6AE22B690506AE448"><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="HD5B271A4F1DF497C98845078BDA7367F"><enum>(b)</enum><header>Procedures for receiving and investigating complaints</header><text>The Secretary shall establish procedures under which—</text><paragraph id="H3496F2D65BBB4EBF93F9A0064C15A32D"><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="H7A008BC3E06E48A9991B65863B7328F0"><enum>(2)</enum><text>such complaints shall be investigated by the Secretary.</text></paragraph></subsection><subsection id="H8494B80A6D554F618724CE3CBF277449"><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="H4FF123598F12439C9727D5B3C6E277E8"><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="H4242A006885C44D689A84D1341E5487B"><enum>(2)</enum><text>may impose civil money penalties, as described in subsection (d).</text></paragraph></subsection><subsection id="H52360638A12041ADB8B6C98A71A91FA4"><enum>(d)</enum><header>Civil penalties</header><paragraph id="H4B5C2DE0347B44DDB661A7CFFFC7BE96"><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="HB1F3E58726F445F69E905B233C3899EC"><enum>(A)</enum><header>Hospital liability</header><text display-inline="yes-display-inline">The Secretary may impose on a hospital found to be in violation of this title a civil money penalty of—</text><clause id="H307691D487644EE88E250D16BCA40B66"><enum>(i)</enum><text>not more than $25,000 for the first knowing violation of this title by such hospital; and</text></clause><clause id="H9C717F930DF0475FA5B1D9CB57CA671D"><enum>(ii)</enum><text>not more than $50,000 for any subsequent knowing violation of this title by such hospital.</text></clause></subparagraph><subparagraph id="H8F393C57890C4626A04135D517B21CC4"><enum>(B)</enum><header>Individual liability</header><text>The Secretary may impose on an individual who—</text><clause id="HCC1730C783654C6BA5746D68AE141242"><enum>(i)</enum><text>is employed by a hospital found by the Secretary to have violated this title; and</text></clause><clause id="HA1BB39662FC44BDF9CA761A5783240A0"><enum>(ii)</enum><text>knowingly 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 by the individual.</continuation-text></subparagraph></paragraph><paragraph id="H252E7941B5B848C58F446CBE4D59EE5A"><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 with respect to a civil money penalty or proceeding under this subsection in the same manner as such provisions apply with respect to a civil money penalty or proceeding under such section 1128A.</text></paragraph></subsection><subsection id="H0F926ACF0730477DA833104388DB7EED"><enum>(e)</enum><header>Public notice of violations</header><paragraph id="H74798F426F2841D7919EA6369EDDEC1C"><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 hospitals on which a civil money penalty has been imposed under this section, the violation for which such penalty was imposed, and such additional information as the Secretary determines appropriate.</text></paragraph><paragraph id="H891E48BC310E45628233FEDC194F100F"><enum>(2)</enum><header>Change of ownership</header><text>With respect to a hospital that had a change of ownership, as determined by the Secretary, penalties imposed on the hospital while under previous ownership shall no longer be published by the Secretary pursuant to paragraph (1) after the 1-year period beginning on the date of change of ownership.</text></paragraph></subsection><subsection id="H32EA66B744674A7398C72A80F86C0A3D"><enum>(f)</enum><header>Use of funds</header><text>Funds collected by the Secretary pursuant to this section are authorized to be appropriated to carry out this title.</text></subsection></section><section id="HF71536F3515D496B9E5D98D5C0E7D968"><enum>3407.</enum><header>Definitions</header><text display-inline="no-display-inline">For purposes of this title:</text><paragraph id="H93BA9682AF2045FA9F3FC53DAD157AC9"><enum>(1)</enum><header>Acuity level</header><text display-inline="yes-display-inline">The term <term>acuity level</term> means the determination, using a hospital acuity measurement tool that has been developed and established in coordination with direct care registered nurses and made transparent pursuant to section 3401(c)(4), of nursing care requirements, based on the assigned direct care registered nurse’s professional judgment of—</text><subparagraph id="H6FFF65709A00422280A22EF36A91D94A"><enum>(A)</enum><text>the severity and complexity of an individual patient’s illness or injury;</text></subparagraph><subparagraph id="H4DF09FEB3758481AB1FD2E4B106B121F"><enum>(B)</enum><text>the need for specialized equipment; and</text></subparagraph><subparagraph id="H6344A74857144C2A94A72992264317EB"><enum>(C)</enum><text>the intensity of nursing interventions required.</text></subparagraph></paragraph><paragraph id="HEA1ECC0F8A2E47BDB1D522A70763BF75"><enum>(2)</enum><header>Competence</header><text>The term <term>competence</term> or <term>competent</term> means the satisfactory application of the duties and responsibilities of a registered nurse in providing nursing care to specific patient populations and for acuity levels for each patient care unit or area pursuant to the State nursing laws and regulations of the State in which the direct nursing care is being performed.</text></paragraph><paragraph id="HB89940BA526A41A3B4292B217DAA297E"><enum>(3)</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 one State to practice as a licensed practical nurse or a licensed vocational nurse and who provides bedside care for one or more patients.</text></paragraph><paragraph id="HC28E47A4D21E44D1808DEA992581E07D"><enum>(4)</enum><header>Direct care registered nurse</header><text>The term <term>direct care registered nurse</term> means an individual who has been granted a license by at least one State to practice as a registered nurse and who provides bedside care for one or more patients.</text></paragraph><paragraph id="HCEBD6D52B0CE46E1ACA1628C0BC4BEEB"><enum>(5)</enum><header>Employment</header><text>The term <term>employment</term> includes the provision of services under a contract or other arrangement.</text></paragraph><paragraph id="H416E3410EB084DD4A9BBB013F3586985"><enum>(6)</enum><header>Hospital</header><text>The term <term>hospital</term> 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, the Department of Defense, the Indian Health Services Program, or any other department or agency of the United States.</text></paragraph><paragraph id="H30FD01BFADF5434F970CA5554CA2E552"><enum>(7)</enum><header>Nurse</header><text>The term <term>nurse</term> means any direct care registered nurse or direct care licensed practice nurse (as the case may be), regardless of whether or not the nurse is an employee.</text></paragraph><paragraph id="H076943B2B4DC430BBA2AE6FB7F66FAA6"><enum>(8)</enum><header>Nursing care plan</header><text display-inline="yes-display-inline">The term <term>nursing care plan</term> means a plan developed by the assigned direct care registered nurse (in accordance with nursing law in the State in which the nursing care is performed) that indicates the nursing care to be given to individual patients that—</text><subparagraph id="H2E0B952107F5439BB2CC8F5F2900102B"><enum>(A)</enum><text>considers the acuity level of the patient;</text></subparagraph><subparagraph id="HFB31366D41704C718F94A35F9E7B9A4F"><enum>(B)</enum><text>is developed in coordination with the patient, the patient’s family, or other representatives when appropriate, and staff of other disciplines involved in the care of the patient;</text></subparagraph><subparagraph id="H36FA11AB458E48F5903A562459961EEA"><enum>(C)</enum><text>reflects all elements of the nursing process; and</text></subparagraph><subparagraph id="HF7D14E8651764C57BBBBA9E3E71BC3AC"><enum>(D)</enum><text>recommends the number and skill mix of additional licensed and unlicensed direct care staff needed to fully implement the nursing care plan.</text></subparagraph></paragraph><paragraph id="H74CE41996EA34FE3984252180C6197DD"><enum>(9)</enum><header>Professional judgment</header><text>The term <term>professional judgment</term> means, in accordance with State nursing laws and regulations of the State in which the direct nursing care is being performed, the direct care registered nurse’s application of knowledge, expertise, and experience in conducting a comprehensive nursing assessment of each patient and in making independent decisions about patient care including the need for additional staff.</text></paragraph><paragraph id="HE8B81982575A4F36AADFFCA980850D85"><enum>(10)</enum><header>Staffing plan</header><text>The term <term>staffing plan</term> means a staffing plan required under section 3401.</text></paragraph><paragraph id="H4C4872C8BCF64BF786784B7E76F1F680"><enum>(11)</enum><header>State of emergency</header><text>The term <term>state of emergency</term>—</text><subparagraph id="H6D2B511382F14FCC83AC0999D15D5D34"><enum>(A)</enum><text>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; and</text></subparagraph><subparagraph id="H7103D37A6651410888EDF28230D5461D"><enum>(B)</enum><text>does not include a state of emergency that results from a labor dispute in the health care industry or consistent understaffing.</text></subparagraph></paragraph></section><section id="H2A90134C752541A49ED43533F0B687A0"><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, if such disclosure is not authorized or required by other applicable law.</text></section>

Minimum direct care registered nurse staffing requirement

(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:

(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).