,i  #aacth ,,congress  #ast ,session    
,h4 ,r4 #ahba  ,,in ,,the ,,house ,,of  
,,representatives  ,april #cj1 #bjac    
,mrs4 ,capps 7for herself and ,mr4      
,joyce7 introduced the following bill2  
which was referred to the ,committee on 
,energy and ,commerce1 and in addition  
to the ,committee on ,ways and ,means1  
for a period to be subsequently         
determined by the ,speaker1 in each case
 for consideration of such provisions as
 fall within the jurisdiction of the    
committee concerned  ,a ,,bill  ,to     
amend title ,,xviii of the ,social      
,security ,act to provide for patient   
protection by establishing safe nurse   
staffing levels at certain ,medicare    
providers1 and for other purposes4  #a4 
,short title ,this ,act may be cited as 
the ,registered ,nurse ,safe ,staffing  
,act of #bjac4  #b4 ,findings ,congress 
makes the following findings3  7#a7     
,research shows that patient safety in  
hospitals is directly proportionate to  
the number of registered nurses working 

in the hospital4 ,higher staffing levels
 by experienced registered nurses are   
related to lower rates of negative      
patient outcomes4  7#b7 ,a #bjaa study  
on nurse staffing and inpatient hospital
 mortality shows that sub-optimal nurse 
staffing is linked with a greater       
likelihood of patient death in the      
hospital4 ,a #bjab study of serious     
patient events reported to the ,joint   
,commission demonstrates that one of the
 leading causes of all hospital sentinel
 events is human factors1 including     
staffing and staffing skill mix4  7#c7  
,health care worker fatigue has been    
identified as a major patient safety    
hazard1 and appropriate staffing        
policies and practices are indicated as 
an effective strategy to reduce health  
care worker fatigue and to protect      
patients4 ,a national survey of         
registered nurses found that #gd percent
 experience acute or chronic effects of 
stress and overwork4  7#d7 ,a strategy  
that ensures optimal nurse staffing and 

skill mix greatly influences patient    
satisfaction and results in greater     
overall savings to hospitals through    
reductions in adverse patient events4   
7#e7 ,a #bjji study demonstrated that   
improved patient satisfaction due to    
increased and appropriate nurse staffing
 is reflected on hospital scores on     
,,hcahps1 which is a key measure for    
value-based payment programs under the  
,medicare program and used by other     
payors4  7#f7 ,registered nurses play a 
vital role in preventing patient care   
errors4 ,a #bjji study found that       
sufficient staffing of critical care    
nurses can prevent adverse patient      
events1 which can cost anywhere from    
#b1bjj1jjj to #ac1bjj1jjj4 ,by contrast1
 the nurse staffing costs in the study  
time period were only #a1cfj1jjj4  7#g7 
,higher nurse staffing also generates   
cost savings to payors1 as demonstrated 
in a #bjaa cost-benefit analysis that   
weighed registered nursing personnel    
costs against emergency department      

utilization after patient discharge from
 a hospital4  7#h7 ,a #bjab study of    
,pennsylvania hospitals shows that by   
reducing nurse burnout1 which is        
attributed in part to poor nurse        
staffing1 those hospitals could prevent 
an estimated #d1afj infections with an  
associated savings of #da1jjj1jjj4 ,that
 study also found that for each         
additional patient assigned to a        
registered nurse for care1 there is an  
incidence of roughly one additional     
catheter-acquired urinary tract         
infection per #a1jjj patients or #a1cea 
infections per year1 costing those      
hospitals as much as #a1ajj1jjj         
annually4  7#i7 ,when hospitals employ  
insufficient numbers of nursing staff1  
registered nurses are being required to 
perform professional services under     
conditions that do not support quality  
health care or a healthful work         
environment for registered nurses4      
7#aj7 ,as a payor for inpatient and     
outpatient hospital services furnished  

to ,medicare beneficiaries1 the ,federal
 ,government has a compelling interest  
in promoting the safety of these        
patients by requiring any hospital      
participating in the ,medicare program  
to establish minimum safe staffing      
levels for registered nurses4  #c4      
,establishment of safe nurse staffing   
levels by ,medicare participating       
hospitals  7a7 ,requirement of medicare 
provider agreement ,section             
#ahff7;a77#a7 of the ,social ,security  
,act 7#db ,u4,s4,c4 #acie;cc7a77#a77 is 
amended--  7#a7 in subparagraph 7,v71 by
 striking and at the end2  7#b7 in      
subparagraph 7,w71 as added by section  
#cjje of the ,patient ,protection and   
,affordable ,care ,act 7,public ,law    
#aaa-adh7--  7,a7 by moving such        
subparagraph #b ems to the left2 and    
7,b7 by striking the period at the end2 
7#c7 in subparagraph 7,w71 as added by  
section #fdjf7;b7 of the ,patient       
,protection and ,affordable ,care ,act  
7,public ,law #aaa-adh7--  7,a7 by      

moving such subparagraph #b ems to the  
left2  7,b7 by redesignating such       
subparagraph as subparagraph 7,x72 and  
7,c7 by striking the period at the end  
and inserting 1 and2 and  7#d7 by       
inserting after subparagraph 7,x71 as   
redesignated by paragraph 7#c77;,b71 the
 following new subparagraph3  7,y7 in   
the case of a hospital 7as defined in   
section #ahfa7;e771 to meet the         
requirements of section #ahii;,b4  4    
7b7 ,requirements ,title ,,xviii of the 
,social ,security ,act 7#db ,u4,s4,c4   
#acie et seq47 is amended by adding at  
the end the following new section3      
#ahii;,b4 ,nurse staffing requirements  
for ,medicare participating hospitals   
7a7 ,implementation of nurse staffing   
plan  7#a7 ,in general ,each            
participating hospital shall implement a
 hospital-wide staffing plan for nursing
 services furnished in the hospital4    
7#b7 ,requirement for development of    
staffing plan by hospital nurse staffing
 committee ,the hospital-wide staffing  

plan for nursing services implemented by
 a hospital pursuant to paragraph 7#a7--
  7,a7 shall be developed by the        
hospital nurse staffing committee       
established under subsection 7b72 and   
7,b7 shall require that an appropriate  
number of registered nurses provide     
direct patient care in each unit and on 
each shift of the hospital to ensure    
staffing levels that--  7i7 address the 
unique characteristics of the patients  
and hospital units2 and  7ii7 result in 
the delivery of safe1 quality patient   
care1 consistent with the requirements  
under subsection 7c74  7b7 ,hospital    
nurse staffing committee  7#a7          
,establishment ,each participating      
hospital shall establish a hospital     
nurse staffing committee 7hereinafter in
 this section referred to as the        
,committee74  7#b7 ,composition ,a      
,committee established pursuant to this 
subsection shall be composed of members 
as follows3  7,a7 ,minimum #ee percent  
nurse participation ,not less than #ee  

percent of the members of the ,committee
 shall be registered nurses who provide 
direct patient care but who are neither 
hospital nurse managers nor part of the 
hospital administration staff4  7,b7    
,inclusion of hospital nurse managers   
,the ,committee shall include members   
who are hospital nurse managers4  7,c7  
,inclusion of nurses from specialty     
units ,the members of the ,committee    
shall include at least #a registered    
nurse who provides direct care from each
 nurse specialty or unit of the hospital
 7each such specialty or unit as        
determined by the hospital74  7,d7      
,other hospital personnel ,the          
,committee shall include such other     
personnel of the hospital as the        
hospital determines to be appropriate4  
7#c7 ,duties  7,a7 ,development of      
staffing plan ,the ,committee shall     
develop a hospital-wide staffing plan   
for nursing services furnished in the   
hospital consistent with the            
requirements under subsection 7c74  7,b7

 ,review and modification of staffing   
plan ,the ,committee shall--  7i7       
conduct regular1 ongoing monitoring of  
the implementation of the hospital-wide 
staffing plan for nursing services      
furnished in the hospital2  7ii7 carry  
out evaluations of the hospital-wide    
staffing plan for nursing services at   
least annually2 and  7iii7 make such    
modifications to the hospital-wide      
staffing plan for nursing services as   
may be appropriate4  7,c7 ,additional   
duties ,the ,committee shall--  7i7     
develop policies and procedures for     
overtime requirements of registered     
nurses providing direct patient care and
 for appropriate time and manner of     
relief of such registered nurses during 
routine absences2 and  7ii7 carry out   
such additional duties as the ,committee
 determines to be appropriate4  7c7     
,staffing plan requirements  7#a7 ,plan 
requirements ,subject to paragraph 7#b71
 a hospital-wide staffing plan for      
nursing services developed and          

implemented under this section shall--  
7,a7 be based upon input from the       
registered nurse staff of the hospital  
who provide direct patient care or their
 exclusive representatives1 as well as  
the chief nurse executive2  7,b7 be     
based upon the number of patients and   
the level and variability of intensity  
of care to be provided to those         
patients1 with appropriate consideration
 given to admissions1 discharges1 and   
transfers during each shift2  7,c7 take 
into account contextual issues affecting
 nurse staffing and the delivery of     
care1 including architecture and        
geography of the environment and        
available technology2  7,d7 take into   
account the level of education1         
training1 and experience of those       
registered nurses providing direct      
patient care2  7,e7 take into account   
the staffing levels and services        
provided by other health care personnel 
associated with nursing care1 such as   
certified nurse assistants1 licensed    

vocational nurses1 licensed psychiatric 
technicians1 nursing assistants1 aides1 
and orderlies2  7,f7 take into account  
staffing levels recommended by specialty
 nursing organizations2  7,g7 establish 
upwardly adjustable minimum ratios of   
direct care registered nurses to        
patients for each unit and for each     
shift of the hospital1 based upon an    
assessment by registered nurses of the  
level and variability of intensity of   
care required by patients under existing
 conditions2  7,h7 take into account    
unit and facility level staffing1       
quality and patient outcome data1 and   
national comparisons1 as available2     
7,i7 ensure that a registered nurse     
shall not be assigned to work in a      
particular unit of the hospital without 
first having established the ability to 
provide professional care in such unit2 
and  7,j7 provide for exemptions from   
some or all requirements of the         
hospital-wide staffing plan for nursing 
services during a declared state of     

emergency 7as defined in subsection     
7l77#a77 if the hospital is requested or
 expected to provide an exceptional     
level of emergency or other medical     
services4  7#b7 ,limitation ,a          
hospital-wide staffing plan for nursing 
services developed and implemented under
 this section--  7,a7 shall not preempt 
any registered-nurse staffing levels    
established under ,state law or         
regulation2 and  7,b7 may not utilize   
any minimum number of registered nurses 
established under paragraph 7#a77;,g7 as
 an upper limit on the nurse staffing of
 the hospital to which such minimum     
number applies4  7d7 ,reporting and     
release to public of certain staffing   
information  7#a7 ,requirements for     
hospitals ,each participating hospital  
shall--  7,a7 post daily for each shift1
 in a clearly visible place1 a document 
that specifies in a uniform manner 7as  
prescribed by the ,secretary7 the       
current number of licensed and          
unlicensed nursing staff directly       

responsible for patient care in each    
unit of the hospital1 identifying       
specifically the number of registered   
nurses2  7,b7 upon request1 make        
available to the public--  7i7 the      
nursing staff information described in  
subparagraph 7,a72  7ii7 a detailed     
written description of the hospital-wide
 staffing plan implemented by the       
hospital pursuant to subsection 7a72 and
  7iii7 not later than #ij days after   
the date on which an evaluation is      
carried out by the ,committee under     
subsection 7b77#c77;,b77ii71 a copy of  
such evaluation2 and  7,c7 not less     
frequently than quarterly1 submit to the
 ,secretary in a uniform manner 7as     
prescribed by the ,secretary7 the       
nursing staff information described in  
subparagraph 7,a7 through electronic    
data submission4  7#b7 ,secretarial     
responsibilities ,the ,secretary shall--
  7,a7 make the information submitted   
pursuant to paragraph 7#a77;,c7 publicly
 available in a comprehensible format   

7as described in subsection             
7e77#b77;,d77ii771 including by         
publication on the ,hospital ,compare   
,internet ,web site of the ,department  
of ,health and ,human ,services2 and    
7,b7 provide for the auditing of such   
information for accuracy as a part of   
the process of determining whether the  
participating hospital is in compliance 
with the conditions of its agreement    
with the ,secretary under section #ahff1
 including under subsection 7a77#a77,y7 
of such section4  7e7 ,recordkeeping2   
collection and reporting of quality     
data2 evaluation  7#a7 ,recordkeeping   
,each participating hospital shall      
maintain for a period of at least #c    
years 7or1 if longer1 until the         
conclusion of any pending enforcement   
activities7 such records as the         
,secretary deems necessary to determine 
whether the hospital has implemented a  
hospital-wide staffing plan for nursing 
services pursuant to subsection 7a74    
7#b7 ,collection and reporting of       

quality data on nursing services  7,a7  
,in general ,the ,secretary shall       
require the collection1 aggregation1    
maintenance1 and reporting of quality   
data relating to nursing services       
furnished by each participating         
hospital4  7,b7 ,use of endorsed        
measures ,in carrying out this          
paragraph1 the ,secretary shall use only
 quality measures for nursing-sensitive 
care that are endorsed by the           
consensus-based entity with a contract  
under section #ahij7;a74  7,c7 ,use of  
qualified third-party entities for      
collection and submission of data  7i7  
,in general ,a participating hospital   
may enter into agreements with          
third-party entities that have          
demonstrated expertise in the collection
 and submission of quality data on      
nursing services to collect1 aggregate1 
maintain1 and report the quality data of
 the hospital pursuant to subparagraph  
7,a74  7ii7 ,construction ,nothing in   
clause 7i7 shall be construed to excuse 

or exempt a participating hospital that 
has entered into an agreement described 
in such clause from compliance with     
requirements for quality data           
collection1 aggregation1 maintenance1   
and reporting imposed under this        
paragraph4  7,d7 ,reporting of quality  
data  7i7 ,publication on hospital      
compare web site ,subject to the        
succeeding provisions of this           
subparagraph1 the ,secretary shall make 
the data submitted pursuant to          
subparagraph 7,a7 publicly available1   
including by publication on the         
,hospital ,compare ,internet ,web site  
of the ,department of ,health and ,human
 ,services4  7ii7 ,comprehensible format
 ,data made available to the public     
under clause 7i7 shall be presented in a
 clearly understandable format that     
permits consumers of hospital services  
to make meaningful comparisons among    
hospitals1 including concise            
explanations in plain ,english of how to
 interpret the data1 of the difference  

in types of nursing staff1 of the       
relationship between nurse staffing     
levels and quality of care1 and of how  
nurse staffing may vary based on patient
 case mix4  7iii7 ,opportunity to       
correct errors ,the ,secretary shall    
establish a process under which         
participating hospitals may review data 
submitted to the ,secretary pursuant to 
subparagraph 7,a7 to correct errors1 if 
any1 contained in that data submission  
before making the data available to the 
public under clause 7i74  7#c7          
,evaluation of data ,the ,secretary     
shall provide for the analysis of       
quality data collected from             
participating hospitals under paragraph 
7#b7 in order to evaluate the effect of 
hospital-wide staffing plans for nursing
 services implemented pursuant to       
subsection 7a7 on--  7,a7 patient       
outcomes that are nursing sensitive     
7such as pressure ulcers1 fall          
occurrence1 falls resulting in injury1  
length of stay1 and central line        

catheter infections72 and  7,b7 nursing 
workforce safety and retention          
7including work-related injury1 staff   
skill mix1 nursing care hours per       
patient day1 vacancy and voluntary      
turnover rates1 overtime rates1 use of  
temporary agency personnel1 and nurse   
satisfaction74  7f7 ,refusal of         
assignment ,a nurse may refuse to accept
 an assignment as a nurse in a          
participating hospital1 or in a unit of 
a participating hospital1 if--  7#a7 the
 assignment is in violation of the      
hospital-wide staffing plan for nursing 
services implemented pursuant to        
subsection 7a72 or  7#b7 the nurse is   
not prepared by education1 training1 or 
experience to fulfill the assignment    
without compromising the safety of any  
patient or jeopardizing the license of  
the nurse4  7g7 ,enforcement  7#a7      
,responsibility ,the ,secretary shall   
enforce the requirements and            
prohibitions of this section in         
accordance with the succeeding          

provisions of this subsection4  7#b7    
,procedures for receiving and           
investigating complaints ,the ,secretary
 shall establish procedures under       
which--  7,a7 any person may file a     
complaint that a participating hospital 
has violated a requirement of or a      
prohibition under this section2 and     
7,b7 such complaints are investigated by
 the ,secretary4  7#c7 ,remedies ,except
 as provided in paragraph 7#e71 if the  
,secretary determines that a            
participating hospital has violated a   
requirement of this section1 the        
,secretary--  7,a7 shall require the    
hospital to establish a corrective      
action plan to prevent the recurrence of
 such violation2 and  7,b7 may impose   
civil money penalties under paragraph   
7#d74  7#d7 ,civil money penalties  7,a7
 ,in general ,in addition to any other  
penalties prescribed by law1 the        
,secretary may impose a civil money     
penalty of not more than #aj1jjj for    
each knowing violation of a requirement 

of this section1 except that the        
,secretary shall impose a civil money   
penalty of more than #aj1jjj for each   
such violation in the case of a         
participating hospital that the         
,secretary determines has a pattern or  
practice of such violations 7with the   
amount of such additional penalties     
being determined in accordance with a   
schedule or methodology specified in    
regulations74  7,b7 ,procedures ,the    
provisions of section #aabh;,a 7other   
than subsections 7a7 and 7b77 shall     
apply to a civil money penalty under    
this paragraph in the same manner as    
such provisions apply to a penalty or   
proceeding under section #aabh;,a4  7,c7
 ,public notice of violations  7i7      
,internet web site ,the ,secretary shall
 publish on an appropriate ,internet    
,web site of the ,department of ,health 
and ,human ,services the names of       
participating hospitals on which civil  
money penalties have been imposed under 
this section1 the violation for which   

the penalty was imposed1 and such       
additional information as the ,secretary
 determines appropriate4  7ii7 ,change  
of ownership ,with respect to a         
participating hospital that had a change
 in ownership1 as determined by the     
,secretary1 penalties imposed on the    
hospital while under previous ownership 
shall no longer be published by the     
,secretary of such ,internet ,web site  
after the #a-year period beginning on   
the date of the change in ownership4    
7#e7 ,penalty for failure to collect and
 report quality data on nursing services
  7,a7 ,in general ,in the case of a    
participating hospital that fails to    
comply with requirements under          
subsection 7e77#b7 to collect1          
aggregate1 maintain1 and report quality 
data relating to nursing services       
furnished by the hospital1 instead of   
the remedies described in paragraph     
7#c71 the provisions of subparagraph    
7,b7 shall apply with respect to each   
such failure of the participating       

hospital4  7,b7 ,penalty ,in the case of
 a failure by a participating hospital  
to comply with the requirements under   
subsection 7e77#b7 for a year1 each such
 failure shall be deemed to be a failure
 to submit data required under section  
#ahcc7t77#ag77;,a71 section             
#ahhf7;b77#c77;,b77viii71 section       
#ahhf7;j77#g77;,a71 or section          
#ahhf7m77#e77;,a71 as the case may be1  
with respect to the participating       
hospital involved for that year4  7h7   
,whistleblower protections  7#a7        
,prohibition of discrimination and      
retaliation ,a participating hospital   
shall not discriminate or retaliate in  
any manner against any patient or       
employee of the hospital because that   
patient or employee1 or any other       
person1 has presented a grievance or    
complaint1 or has initiated or          
cooperated in any investigation or      
proceeding of any kind1 relating to--   
7,a7 the hospital-wide staffing plan for
 nursing services developed and         

implemented under this section2 or  7,b7
 any right1 other requirement or        
prohibition under this section1         
including a refusal to accept an        
assignment described in subsection 7f74 
7#b7 ,relief for prevailing employees   
,an employee of a participating hospital
 who has been discriminated or          
retaliated against in employment in     
violation of this subsection may        
initiate judicial action in a ,united   
,states district court and shall be     
entitled to reinstatement1 reimbursement
 for lost wages1 and work benefits      
caused by the unlawful acts of the      
employing hospital4 ,prevailing         
employees are entitled to reasonable    
attorney's fees and costs associated    
with pursuing the case4  7#c7 ,relief   
for prevailing patients ,a patient who  
has been discriminated or retaliated    
against in violation of this subsection 
may initiate judicial action in a       
,united ,states district court4 ,a      
prevailing patient shall be entitled to 

liquidated damages of #e1jjj for a      
violation of this statute in addition to
 any other damages under other          
applicable statutes1 regulations1 or    
common law4 ,prevailing patients are    
entitled to reasonable attorney's fees  
and costs associated with pursuing the  
case4  7#d7 ,limitation on actions ,no  
action may be brought under paragraph   
7#b7 or 7#c7 more than #b years after   
the discrimination or retaliation with  
respect to which the action is brought4 
7#e7 ,treatment of adverse employment   
actions ,for purposes of this           
subsection--  7,a7 an adverse employment
 action shall be treated as             
discrimination or retaliation2 and  7,b7
 the term adverse employment action     
includes--  7i7 the failure to promote  
an individual or provide any other      
employment-related benefit for which the
 individual would otherwise be eligible2
  7ii7 an adverse evaluation or decision
 made in relation to accreditation1     
certification1 credentialing1 or        

licensing of the individual2 and  7iii7 
a personnel action that is adverse to   
the individual concerned4  7i7          
,relationship to state laws ,nothing in 
this section shall be construed as      
exempting or relieving any person from  
any liability1 duty1 penalty1 or        
punishment provided by the law of any   
,state or political subdivision of a    
,state1 other than any such law which   
purports to require or permit any action
 prohibited under this title4  7j7      
,relationship to conduct prohibited     
under the national labor relations act  
or other collective bargaining laws     
,nothing in this section shall be       
construed as--  7#a7 permitting conduct 
prohibited under the ,national ,labor   
,relations ,act or under any other      
,federal1 ,state1 or local collective   
bargaining law2 or  7#b7 preempting1    
limiting1 or modifying a collective     
bargaining agreement entered into by a  
participating hospital4  7k7            
,regulations  7#a7 ,in general ,the     

,secretary shall promulgate such        
regulations as are appropriate and      
necessary to implement this section4    
7#b7 ,implementation  7,a7 ,in general  
,except as provided in subparagraph     
7,b71 as soon as practicable but not    
later than #b years after the date of   
the enactment of this section1 a        
participating hospital shall have       
implemented a hospital-wide staffing    
plan for nursing services under this    
section4  7,b7 ,special rule for rural  
hospitals ,in the case of a             
participating hospital located in a     
rural area 7as defined in section       
#ahhf7;d77#b77;,d771 such participating 
hospital shall have implemented a       
hospital-wide staffing plan for nursing 
services under this section as soon as  
practicable but not later than #d years 
after the date of the enactment of this 
section4  7l7 ,definitions ,in this     
section3  7#a7 ,declared state of       
emergency ,the term declared state of   
emergency means an officially designated

 state of emergency that has been       
declared by the ,federal ,government or 
the head of the appropriate ,state or   
local governmental agency having        
authority to declare that the ,state1   
county1 municipality1 or locality is in 
a state of emergency1 but does not      
include a state of emergency that       
results from a labor dispute in the     
health care industry or consistent      
understaffing4  7#b7 ,participating     
hospital ,the term participating        
hospital means a hospital 7as defined in
 section #ahfa7;e77 that has entered    
into a provider agreement under section 
#ahff4  7#c7 ,person ,the term person   
means one or more individuals1          
associations1 corporations1             
unincorporated organizations1 or labor  
unions4  7#d7 ,registered nurse ,the    
term registered nurse means an          
individual who has been granted a       
license to practice as a registered     
nurse in at least #a ,state4  7#e7      
,shift ,the term shift means a scheduled

 set of hours or duty period to be      
worked at a participating hospital4     
7#f7 ,unit ,the term unit means1 with   
respect to a hospital1 an organizational
 department or separate geographic area 
of a hospital1 including a burn unit1 a 
labor and delivery room1 a              
post-anesthesia service area1 an        
emergency department1 an operating room1
 a pediatric unit1 a stepdown or        
intermediate care unit1 a specialty care
 unit1 a telemetry unit1 a general      
medical care unit1 a subacute care unit1
 and a transitional inpatient care unit4
  4