,i #aac? ,,congress #a/ ,session ,h4 ,r4 #aijg ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,may #i1 #bjac ,ms4 ,s*ak[sky 7= h]self1 ,ms4 ,l(gr51 ,ms4 ,norton1 ,ms4 ,s*w>tz1 ,ms4 ,moore1 ,mr4 ,%]man1 ,ms4 ,lee ( ,cali=nia1 ,mr4 ,ellison1 ,ms4 ,*u1 & ,mr4 ,lyn*7 introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,en]gy & ,comm]ce1 & 9 addition to ! ,committee on ,ways & ,means1 = a p]iod to be subsequ5tly det]m9$ by ! ,speak]1 9 ea* case = consid]ation ( su* provisions z fall )9 ! jurisdiction ( ! committee conc]n$ ,a ,,bill ,to am5d ! ,public ,heal? ,s]vice ,act to e/abli% direct c>e regi/]$ nurse-to-pati5t /aff+ ratio requirem5ts 9 hospitals1 & = o!r purposes4 #a4 ,%ort title2 table ( cont5ts2 f9d+s 7a7 ,%ort title ,?is ,act may be cit$ z ! ,nurse ,/aff+ ,/&>ds = ,pati5t ,safety & ,quality ,c>e ,act ( #bjac4 7b7 ,table ( cont5ts ,! table ( cont5t = ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts2 f9d+s4 ,sec4 #b4 ,m9imum direct c>e regi/]$ nurse /aff+ requirem5t4 ,sec4 #c4 ,en=cem5t ( requirem5ts ?r\gh ,f$]al programs4 ,sec4 #d4 ,nurse ,work=ce ,initiative4 7c7 ,f9d+s ,congress f9ds ! foll[+3 7#a7 ,! ,f$]al ,gov]nm5t has a sub/antial int]e/ 9 promot+ quality c>e & improv+ ! deliv]y ( heal? c>e s]vices to pati5ts 9 heal? c>e facilities 9 ! ,unit$ ,/ates4 7#b7 ,rec5t *anges 9 heal? c>e deliv]y sy/ems t h result$ 9 high] acuity levels among pati5ts 9 heal? c>e facilities increase ! ne$ = improv$ quality measures 9 ord] to protect pati5t c>e & r$uce ! incid5ce ( m$ical errors4 7#c7 ,inadequate & poorly monitor$ regi/]$ nurse /aff+ practices t result 9 too few regi/]$ nurses provid+ direct c>e jeop>dize ! deliv]y ( quality heal? c>e s]vices4 7#d7 ,num]\s /udies h %[n t pati5t outcomes are directly correlat$ to direct c>e regi/]$ nurse /aff+ levels1 includ+ a #bjjb ,jo9t ,commission on ,accr$itation ( ,heal?c>e ,organizations report t conclud$ t ! lack ( direct c>e regi/]$ nurses contribut$ to ne>ly a qu>t] ( ! unanticipat$ problems t result 9 injury or dea? to hospital pati5ts4 7#e7 ,requirem5ts = direct c>e regi/]$ nurse /aff+ ratios w help address ! regi/]$ nurse %ortage 9 ! ,unit$ ,/ates by aid+ 9 recruitm5t ( new regi/]$ nurses & improv+ ret5tion ( regi/]$ nurses :o are consid]+ leav+ direct pati5t c>e because ( dem&s creat$ by inadequate /aff+4 7#f7 ,e/abli%+ adequate m9imum direct c>e regi/]$ nurse-to-pati5t ratios t take into acc\nt pati5t acuity measures w improve ! deliv]y ( quality heal? c>e s]vices & gu>antee pati5t safety4 7#g7 ,e/abli%+ safe /aff+ /&>ds = direct c>e regi/]$ nurses is a critical compon5t ( assur+ t !re is adequate hospital /aff+ at all levels to improve ! deliv]y ( quality c>e & protect pati5t safety4 #b4 ,m9imum direct c>e regi/]$ nurse /aff+ requirem5t 7a7 ,m9imum ,direct ,c>e ,regi/]$ ,nurse ,/aff+ ,requirem5ts ,! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bja et seq47 is am5d$ by add+ at ! end ! foll[+ new title3 ,,xxxiv ,,m9imum ,,direct ,,c>e ,,regi/]$ ,,nurse ,,/aff+ ,,requirem5t #cdja4 ,m9imum nurse /aff+ requirem5t 7a7 ,/aff+ plan 7#a7 ,9 g5]al ,a hospital %all implem5t a /aff+ plan t-- 7,a7 provides adequate1 appropriate1 & quality deliv]y ( heal? c>e s]vices & protects pati5t safety2 & 7,b7 is consi/5t ) ! requirem5ts ( ?is title4 7#b7 ,effective dates 7,a7 ,implem5tation ( /aff+ plan ,subject to subp>agraph 7,b71 ! requirem5ts "u p>agraph 7#a7 %all take effect n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is title4 7,b7 ,application ( m9imum direct c>e regi/]$ nurse-to-pati5t ratios ,! requirem5ts "u subsection 7b7 %all take effect z soon z practicable1 z det]m9$ by ! ,secret>y1 b n lat] ?an #b ye>s aft] ! date ( ! enactm5t ( ?is title1 or 9 ! case ( a hospital 9 a rural area 7z def9$ 9 section #ahhf7;d77#b77;,d7 ( ! ,social ,security ,act71 n lat] ?an #d ye>s aft] ! date ( ! enactm5t ( ?is title4 7b7 ,m9imum direct c>e regi/]$ nurse-to-,pati5t ratios 7#a7 ,9 g5]al ,except z provid$ 9 p>agraph 7#d7 & o!r provisions ( ?is section1 a hospital's /aff+ plan %all provide t1 at all times dur+ ea* %ift )9 a unit ( ! hospital1 a direct c>e regi/]$ nurse may be assign$ to n m ?an ! foll[+ numb] ( pati5ts 9 t unit3 7,a7 ,"o pati5t 9 trauma em]g5cy units4 7,b7 ,"o pati5t 9 op]at+ room units1 provid$ t a m9imum ( #a additional p]son s]ves z a scrub assi/ant 9 su* unit4 7,c7 ,two pati5ts 9 critical c>e units1 includ+ neonatal int5sive c>e units1 em]g5cy critical c>e & int5sive c>e units1 labor & deliv]y units1 coron>y c>e units1 acute respiratory c>e units1 po/ane/hesia units1 & burn units4 7,d7 ,?ree pati5ts 9 em]g5cy room units1 p$iatrics units1 /epd[n units1 telemetry units1 antep>tum units1 & comb9$ labor1 deliv]1 & po/p>tum units4 7,e7 ,f\r pati5ts 9 m$ical-surgical units1 int]m$iate c>e nurs]y units1 acute c>e psy*iatric units1 & o!r specialty c>e units4 7,f7 ,five pati5ts 9 rehabilitation units & skill$ nurs+ units4 7,g7 ,six pati5ts 9 po/p>tum 7#c c\plets7 units & well-baby nurs]y units4 7#b7 ,simil> units ) diff]5t names ,! ,secret>y may apply m9imum direct c>e regi/]$ nurse-to-pati5t ratios e/abli%$ 9 p>agraph 7#a7 = a hospital unit ref]r$ to 9 su* p>agraph to a type ( hospital unit n ref]r$ to 9 su* p>agraph if su* type ( hospital unit provides a level ( c>e to pati5ts ^: ne$s are simil> to ! ne$s ( pati5ts c>$ = 9 ! hospital unit ref]r$ to 9 su* p>agraph4 7#c7 ,re/rictions 7,a7 ,prohibition aga9/ av]ag+ ,a hospital %all n av]age ! numb] ( pati5ts & ! total numb] ( direct c>e regi/]$ nurses assign$ to pati5ts 9 a hospital unit dur+ any #a %ift or ov] any p]iod ( "t = purposes ( meet+ ! requirem5ts "u ?is subsection4 7,b7 ,prohibition aga9/ imposition ( m&atory ov]time requirem5ts ,a hospital %all n impose m&atory ov]time requirem5ts to meet ! hospital unit direct c>e regi/]$ nurse-to-pati5t ratios requir$ "u ?is subsection4 7,c7 ,relief dur+ r\t9e abs5ces ,a hospital %all ensure t only a direct c>e regi/]$ nurse may relieve ano!r direct c>e regi/]$ nurse dur+ breaks1 meals1 & o!r r\t9e1 expect$ abs5ces f a hospital unit4 7#d7 ,adju/m5t ( ratios 7,a7 ,9 g5]al ,if necess>y to protect pati5t safety1 ! ,secret>y may prescribe regulations t-- 7i7 increase m9imum direct c>e regi/]$ nurse-to-pati5t ratios "u ?is subsection to fur!r limit ! numb] ( pati5ts t may be assign$ to ea* direct c>e nurse2 or 7ii7 add m9imum direct c>e regi/]$ nurse-to-pati5t ratios = units n ref]r$ to 9 p>agraphs 7#a7 & 7#b74 7,b7 ,consultation ,su* regulations %all be prescrib$ aft] consultation ) affect$ hospitals & regi/]$ nurses4 7#e7 ,relation%ip to /ate-impos$ ratios ,no?+ 9 ?is title %all preempt ,/ate /&>ds t ! ,secret>y det]m9es to be at lea/ equival5t to ,f$]al requirem5ts = a /aff+ plan e/abli%$ "u ?is title4 ,m9imum direct c>e regi/]$ nurse-to-pati5t ratios e/abli%$ "u ?is subsection %all n preempt ,/ate requirem5ts t ! ,secret>y det]m9es are at lea/ equival5t to ,f$]al requirem5ts = a /aff+ plan e/abli%$ "u ?is title4 7#f7 ,exemption 9 em]g5cies ,! requirem5ts e/abli%$ "u ?is subsection %all n apply dur+ a /ate ( em]g5cy if a hospital is reque/$ or expect$ to provide an exceptional level ( em]g5cy or o!r m$ical s]vices4 ,! ,secret>y %all issue guidance to hospitals t describes situations t con/itute a /ate ( em]g5cy = purposes ( ! exemption "u ?is p>agraph4 7c7 ,developm5t & reevaluation ( /aff+ plan 7#a7 ,consid]ations 9 developm5t ( plan ,9 develop+ ! /aff+ plan1 a hospital %all provide = direct c>e regi/]$ nurse-to-pati5t ratios above ! m9imum direct c>e regi/]$ nurse-to-pati5t ratios requir$ "u subsection 7b7 if appropriate bas$ ^u consid]ation ( ! foll[+ factors3 7,a7 ,! numb] ( pati5ts & acuity level ( pati5ts z det]m9$ by ! application ( an acuity sy/em 7z def9$ 9 section #cdjf7a771 on a %ift-by-%ift basis4 7,b7 ,! anticipat$ admissions1 dis*>ges1 & transf]s ( pati5ts dur+ ea* %ift t impacts direct pati5t c>e4 7,c7 ,specializ$ exp]i5ce requir$ ( direct c>e regi/]$ nurses on a p>ticul> unit4 7,d7 ,/aff+ levels & s]vices provid$ by lic5s$ vocational or practical nurses1 lic5s$ psy*iatric te*nicians1 c]tifi$ nurse assi/ants1 or o!r ancill>y /aff 9 meet+ direct pati5t c>e ne$s n requir$ by a direct c>e regi/]$ nurse4 7,e7 ,! level ( te*nology available t affects ! deliv]y ( direct pati5t c>e4 7,f7 ,! level ( famili>ity ) hospital practices1 policies1 & proc$ures by tempor>y ag5cy direct c>e regi/]$ nurses us$ dur+ a %ift4 7,g7 ,ob/acles to effici5cy 9 ! deliv]y ( pati5t c>e pres5t$ by physical lay\t4 7#b7 ,docum5tation ( /aff+ ,a hospital %all specify ! sy/em us$ to docum5t actual /aff+ 9 ea* unit = ea* %ift4 7#c7 ,annual reevaluation ( plan & acuity sy/em 7,a7 ,9 g5]al ,a hospital %all annually evaluate-- 7i7 its /aff+ plan 9 ea* unit 9 relation to actual pati5t c>e requirem5ts2 & 7ii7 ! accuracy ( its acuity sy/em4 7,b7 ,update ,a hospital %all update its /aff+ plan & acuity sy/em to ! ext5t appropriate bas$ on su* evaluation4 7#d7 ,transp>5cy 7,a7 ,9 ,g5]al ,any acuity-bas$ pati5t classification sy/em adopt$ by a hospital "u ?is section %all be transp>5t 9 all respects1 includ+ disclosure ( detail$ docum5tation ( ! me?odology us$ to pr$ict nurs+ /aff+1 id5tify+ ea* factor1 assumption1 & value us$ 9 apply+ su* me?odology4 7,b7 ,public availability ,! ,secret>y %all e/abli% proc$ures to provide t ! docum5tation submitt$ "u subsection 7e7 is available = public inspection 9 its entirety4 7#e7 ,regi/]$ nurse p>ticipation ,a /aff+ plan ( a hospital %all be develop$ & subsequ5t reevaluations %all be conduct$ "u ?is subsection on ! basis ( input f direct c>e regi/]$ nurses at ! hospital or1 :]e su* nurses are repres5t$ ?r\gh collective b>ga9+1 f ! applicable recogniz$ or c]tifi$ collective b>ga9+ repres5tative ( su* nurses4 ,no?+ 9 ?is title %all be con/ru$ to p]mit conduct prohibit$ "u ! ,national ,labor ,relations ,act or "u ! ,f$]al ,labor ,relations ,act4 7d7 ,acuity tool 7#a7 ,9 g5]al ,n lat] ?an #b ye>s aft] ! date ( enactm5t ( ?is title1 ! ,secret>y %all develop a process to e/abli% a national acuity tool t provides a transp>5t me?od = e/abli%+ nurse /aff+ requirem5ts t exce$ ! m9imum hospital unit direct c>e regi/]$ nurse-to-pati5t ratios requir$ "u subsection 7b74 7#b7 ,implem5tation ,ea* hospital unit %all adopt & implem5t ! national acuity tool describ$ 9 p>agraph 7#a71 & provide /aff+ bas$ on su* tool4 ,any additional direct c>e regi/]$ nurs+ /aff+ above ! hospital unit direct c>e regi/]$ nurse-to-pati5t ratios describ$ 9 subsection 7b7 %all be assign$ 9 a mann] det]m9$ by su* national acuity tool4 7e7 ,submission ( plan to secret>y ,a hospital %all submit to ! ,secret>y its /aff+ plan & any annual updates "u subsection 7c77#c77;,b74 ,a f$]ally op]at$ hospital may submit its /aff+ plan ?r\gh ! dep>tm5t or ag5cy op]at+ ! hospital4 #cdjb4 ,po/+1 records1 & audits 7a7 ,po/+ requirem5ts ,9 ea* unit1 a hospital %all po/ a uni=m notice 9 a =m specifi$ by ! ,secret>y 9 regulation t-- 7#a7 expla9s requirem5ts impos$ "u section #cdja2 7#b7 includes actual direct c>e regi/]$ nurse-to-pati5t ratios dur+ ea* %ift2 & 7#c7 is visible1 conspicu\s1 & accessible to /aff1 pati5ts1 & ! public4 7b7 ,records 7#a7 ,ma9t5ance ( records ,ea* hospital %all ma9ta9 accurate records ( actual direct c>e regi/]$ nurse-to-pati5t ratios 9 ea* unit = ea* %ift = no less ?an #c ye>s4 ,su* records %all include-- 7,a7 ! numb] ( pati5ts 9 ea* unit2 7,b7 ! id5tity & duty h\rs ( ea* direct c>e regi/]$ nurse assign$ to ea* pati5t 9 ea* unit 9 ea* %ift2 & 7,c7 a copy ( ea* notice po/$ "u subsection 7a74 7#b7 ,availability ( records ,ea* hospital %all make its records ma9ta9$ "u p>agraph 7#a7 available to-- 7,a7 ! ,secret>y2 7,b7 regi/]$ nurses & _! collective b>ga9+ repres5tatives 7if any72 & 7,c7 ! public "u regulations e/abli%$ by ! ,secret>y1 or 9 ! case ( a f$]ally op]at$ hospital1 "u section #eeb ( title #e1 ,unit$ ,/ates ,code 7commonly kn[n z ! ,fre$om ( ,in=mation ,act74 7c7 ,audits ,! ,secret>y %all conduct p]iodic audits to ensure-- 7#a7 implem5tation ( ! /aff+ plan 9 accordance ) ?is title2 & 7#b7 accuracy 9 records ma9ta9$ "u ?is section4 #cdjc4 ,m9imum direct c>e lic5s$ practical nurse /aff+ requirem5ts 7a7 ,e/abli%m5t ,a hospital's /aff+ plan %all comply ) m9imum direct c>e lic5s$ practical nurse /aff+ requirem5ts t ! ,secret>y e/abli%es = units 9 hospitals4 ,su* /aff+ requirem5ts %all be e/abli%$ n lat] ?an #ah mon?s aft] ! date ( ! enactm5t ( ?is title1 & %all be bas$ on ! /udy conduct$ "u subsection 7b74 7b7 ,/udy ,n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is title1 ! ,secret>y1 act+ ?r\gh ! ,director ( ! ,ag5cy = ,heal?c>e ,rese>* & ,quality1 %all complete a /udy ( lic5s$ practical nurse /aff+ & its effects on pati5t c>e 9 hospitals4 ,! ,director may contract ) a qualifi$ entity or organization to c>ry out su* /udy "u ?is p>agraph4 ,! ,director %all consult ) lic5s$ practical nurses & organizations repres5t+ lic5s$ practical nurses reg>d+ ! design & conduct ( ! /udy4 7c7 ,application ( regi/]$ nurse provisions to lic5s$ practical nurse /aff+ requirem5ts ,p>agraphs 7#b71 7#c71 7#d77;,a71 & 7#e7 ( section #cdja7;b71 section #cdja7;c71 & section #cdjb %all apply to ! e/abli%m5t & application ( direct c>e lic5s$ practical nurse /aff+ requirem5ts "u ?is section 9 ! same mann] t !y apply to ! e/abli%m5t & application ( direct c>e regi/]$ nurse-to-pati5t ratios "u sections #cdja & #cdjb4 7d7 ,effective date ,! requirem5ts ( ?is section %all take effect z soon z practicable1 z det]m9$ by ! ,secret>y1 b n lat] ?an #b ye>s aft] ! date ( ! enactm5t ( ?is title1 or 9 ! case ( a hospital 9 a rural area 7z def9$ 9 section #ahhf7;d77#b77;,d7 ( ! ,social ,security ,act71 n lat] ?an #d ye>s aft] ! date ( ! enactm5t ( ?is title4 #cdjd4 ,adju/m5t 9 reimbursem5t 7a7 ,m$ic>e reimbursem5t ,! ,secret>y %all adju/ paym5ts made to hospitals 7o!r ?an f$]ally op]at$ hospitals7 "u title ,,xviii ( ! ,social ,security ,act 9 an am\nt equal to ! net am\nt ( additional co/s incurr$ 9 provid+ s]vices to ,m$ic>e b5efici>ies t are attributable to compliance ) requirem5ts impos$ "u sections #cdja ?r\gh #cdjc4 ,! am\nt ( su* paym5t adju/m5ts %all take into acc\nt recomm5dations conta9$ 9 ! report submitt$ by ! ,m$ic>e ,paym5t ,advisory ,commission "u subsection 7c74 7b7 ,au?orization ( appropriation = f$]ally op]at$ hospitals ,!re are au?oriz$ to be appropriat$ su* additional sums z are requir$ = f$]ally op]at$ hospitals to comply ) ! additional requirem5ts e/abli%$ "u sections #cdja ?r\gh #cdjc4 7c7 ,m$pac report ,n lat] ?an #b ye>s aft] ! date ( ! enactm5t ( ?is title1 ! ,m$ic>e ,paym5t ,advisory ,commission 7e/abli%$ "u section #ahje ( ! ,social ,security ,act7 %all submit to ,congress & ! ,secret>y a report e/imat+ total co/s & sav+s attributable to compliance ) requirem5ts impos$ "u sections #cdja ?r\gh #cdjc4 ,su* report %all include recomm5dations on ! ne$1 if any1 to adju/ reimbursem5t = ,m$ic>e paym5ts "u subsection 7a74 #cdje4 ,:i/lebl[] & pati5t protections 7a7 ,objection to or refusal ( assignm5t ,a nurse may object to1 or refuse to p>ticipate 91 any activity1 policy1 practice1 assignm5t or task if 9 good fai?-- 7#a7 ! nurse reasonably believes x to be 9 violation ( section #cdja or #cdjc2 or 7#b7 ! nurse is n prep>$ by education1 tra9+1 or exp]i5ce to fulfill ! assignm5t )\t compromis+ ! safety ( any pati5t or jeop>diz+ ! lic5se ( ! nurse4 7b7 ,retaliation = objection to or refusal ( assignm5t b>r$ 7#a7 ,no dis*>ge1 discrim9ation1 or retaliation ,no hospital %all dis*>ge1 retaliate1 discrim9ate1 or o!rwise take adv]se action 9 any mann] ) respect to any aspect ( a nurse's employm5t 7z def9$ 9 section #cdjg7d771 includ+ dis*>ge1 promotion1 comp5sation1 or t]ms1 conditions1 or privileges ( employm5t1 bas$ on ! nurse's refusal ( a "w assignm5t "u subsection 7a74 7#b7 ,no fil+ ( compla9t ,no hospital %all file a compla9t or a report aga9/ a nurse ) a ,/ate pr(essional discipl9>y ag5cy because ( ! nurse's refusal ( a "w assignm5t "u subsection 7a74 7c7 ,cause ( action ,any nurse :o has be5 dis*>g$1 discrim9at$ aga9/1 or retaliat$ aga9/ 9 violation ( subsection 7b77#a7 or aga9/ :om a compla9t or report has be5 fil$ 9 violation ( subsection 7b77#b7 may 7)\t reg>d to :e!r a compla9t has be5 fil$ "u subsection 7d7 ( ?is section or subsection 7b7 ( section #cdjf7 br+ a cause ( action 9 a ,unit$ ,/ates di/rict c\rt4 ,a nurse :o prevails on ! cause ( action %all be entitl$ to "o or m ( ! foll[+3 7#a7 ,re9/atem5t4 7#b7 ,reimbursem5t ( lo/ wages1 comp5sation1 & b5efits4 7#c7 ,attorneys' fees4 7#d7 ,c\rt co/s4 7#e7 ,o!r damages4 7d7 ,compla9t to ,secret>y ,a nurse1 pati5t1 or o!r individual may file a compla9t ) ! ,secret>y aga9/ a hospital t violates ! provisions ( ?is title4 ,= any compla9t fil$1 ! ,secret>y %all-- 7#a7 receive & inve/igate ! compla9t2 7#b7 det]m9e :e!r a violation ( ?is title z alleg$ 9 ! compla9t has occurr$2 & 7#c7 if su* a violation has occurr$1 issue an ord] t ! compla9+ nurse or individual %all n suff] any dis*>ge1 retaliation1 discrim9ation1 or o!r adv]se action prohibit$ by subsection 7b7 or subsection 7f74 7e7 ,toll-,free telephone numb] 7#a7 ,9 g5]al ,! ,secret>y %all provide = ! e/abli%m5t ( a toll-free telephone hotl9e to provide in=mation reg>d+ ! requirem5ts "u sections #cdja ?r\gh #cdjc & to receive reports ( violations ( su* section4 7#b7 ,notice to pati5ts ,a hospital %all provide ea* pati5t admitt$ to ! hospital = inpati5t c>e ) ! hotl9e describ$ 9 p>agraph 7#a71 & %all give notice to ea* pati5t t su* hotl9e may be us$ to report inadequate /aff+ or c>e4 7f7 ,protection = report+ 7#a7 ,prohibition on retaliation or discrim9ation ,a hospital %all n discrim9ate or retaliate 9 any mann] aga9/ any pati5t1 employee1 or contract employee ( ! hospital1 or any o!r individual1 on ! basis t su* individual1 9 good fai?1 individually or 9 conjunction ) ano!r p]son or p]sons1 has pres5t$ a grievance or compla9t1 or has initiat$ or coop]at$ 9 any inve/igation or proce$+ ( any gov]nm5tal entity1 regulatory ag5cy1 or private accr$itation body1 made a civil claim or dem&1 or fil$ an action relat+ to ! c>e1 s]vices1 or conditions ( ! hospital or ( any affiliat$ or relat$ facilities4 7#b7 ,good fa? def9$ ,= purposes ( ?is subsection1 an individual %all be deem$ to be act+ 9 good fai? if ! individual reasonably believes-- 7,a7 ! in=mation report$ or disclos$ is true2 & 7,b7 a violation ( ?is title has occurr$ or may occur4 7g7 ,prohibition on int]f]5ce ) rights 7#a7 ,ex]cise ( rights ,x %all be unlawful = any hospital to-- 7,a7 int]f]e )1 re/ra91 or d5y ! ex]cise1 or attempt to ex]cise1 by any p]son ( any "r provid$ or protect$ "u ?is title2 or 7,b7 co]ce or intimidate any p]son reg>d+ ! ex]cise or attempt to ex]cise su* "r4 7#b7 ,opposition to unlawful policies or practices ,x %all be unlawful = any hospital to discrim9ate or retaliate aga9/ any p]son = oppos+ any hospital policy1 practice1 or actions :i* are alleg$ to violate1 brea*1 or fail to comply ) any provision ( ?is title4 7#c7 ,prohibition on int]f]5ce ) protect$ communications ,a hospital 7or an individual repres5t+ a hospital7 %all n make1 adopt1 or en=ce any rule1 regulation1 policy1 or practice :i* 9 any mann] directly or indirectly prohibits1 imp$es1 or disc\rages a direct c>e nurse f1 or intimidates1 co]ces1 or induces a direct c>e nurse reg>d+1 engag+ 9 free spee* activities or disclos+ in=mation z provid$ "u ?is title4 7#d7 ,prohibition on int]f]5ce ) collective action ,a hospital 7or an individual repres5t+ a hospital7 %all n 9 any way int]f]e ) ! rights ( nurses to organize1 b>ga9 collectively1 & engage 9 conc]t$ activity "u section #g ( ! ,national ,labor ,relations ,act 7#bi ,u4,s4,c4 #aeg74 7h7 ,notice ,a hospital %all po/ 9 an appropriate location 9 ea* unit a conspicu\s notice 9 a =m specifi$ by ! ,secret>y t-- 7#a7 expla9s ! rights ( nurses1 pati5ts1 & o!r individuals "u ?is section2 7#b7 includes a /atem5t t a nurse1 pati5t1 or o!r individual may file a compla9t ) ! ,secret>y aga9/ a hospital t violates ! provisions ( ?is title2 & 7#c7 provides in/ructions on h[ to file su* a compla9t4 7i7 ,effective date 7#a7 ,refusal2 retaliation2 cause ( action 7,a7 ,9 g5]al ,subsections 7a7 ?r\gh 7c7 %all apply to objections & refusals occurr+ on or aft] ! effective date ( ! provision ( ?is title to :i* ! objection or refusal relates4 7,b7 ,exception ,subsection 7a77#b7 %all n apply to objections or refusals 9 any hospital be=e ! requirem5ts ( section #cdja7;a7 or #cdjc7;a71 z applicable1 apply to t hospital4 7#b7 ,protections = report+ ,subsection 7f77#a7 %all apply to actions occurr+ on or aft] ! effective date ( ! provision to :i* ! violation relates1 except t su* subsection %all apply to initiation1 coop]ation1 or p>ticipation 9 an inve/igation or proce$+ on or aft] ! date ( enactm5t ( ?is title4 7#c7 ,notice ,subsection 7h7 %all take effect #ah mon?s aft] ! date ( enactm5t ( ?is title4 #cdjf4 ,en=cem5t 7a7 ,9 g5]al ,! ,secret>y %all en=ce ! requirem5ts & prohibitions ( ?is title 9 accordance ) ?is section4 7b7 ,proc$ures = receiv+ & inve/igat+ compla9ts ,! ,secret>y %all e/abli% proc$ures "u :i*-- 7#a7 any p]son may file a compla9t alleg+ t a hospital has violat$ a requirem5t or a prohibition ( ?is title2 & 7#b7 su* compla9ts %all be inve/igat$ by ! ,secret>y4 7c7 ,rem$ies ,if ! ,secret>y det]m9es t a hospital has violat$ a requirem5t ( ?is title1 ! ,secret>y-- 7#a7 %all require ! facility to e/abli% a corrective action plan to prev5t ! recurr5ce ( su* violation2 & 7#b7 may impose civil money p5alties1 z describ$ 9 subsection 7d74 7d7 ,civil p5alties 7#a7 ,9 g5]al ,9 addition to any o!r p5alties prescrib$ by law1 ! ,secret>y may impose civil p5alties z foll[s3 7,a7 ,hospital liability ,! ,secret>y may impose on a hospital f\nd to be 9 violation ( ?is title1 a civil money p5alty ( n m ?an #be1jjj = ea* kn[+ violation ( a requirem5t ( ?is title1 except t ! ,secret>y %all impose a civil money p5alty ( m ?an #be1jjj = ea* su* violation 9 ! case ( a p>ticipat+ hospital t ! ,secret>y det]m9es has a patt]n or practice ( su* violations 7) ! am\nt ( su* additional p5alties be+ det]m9$ 9 accordance ) a s*$ule or me?odology specifi$ 9 regulations74 7,b7 ,individual liability ,! ,secret>y may impose on an individual :o-- 7i7 is employ$ by a hospital f\nd by ! ,secret>y to h violat$ a requirem5t ( ?is title2 & 7ii7 willfully violates ?is title1 a civil money p5alty ( n m ?an #bj1jjj = ea* su* violation4 7#b7 ,proc$ures ,! provisions ( section #aabh;,a ( ! ,social ,security ,act 7o!r ?an subsections 7a7 & 7b77 %all apply to a civil money p5alty "u ?is p>agraph 9 ! same mann] z su* provisions apply to a p5alty or proce$+ "u su* section #aabh;,a4 7e7 ,public notice ( violations 7#a7 ,int]net ,web site ,! ,secret>y %all publi% on ! ,int]net ,web site ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices ! names ( p>ticipat+ hospitals on :i* civil money p5alties h be5 impos$ "u ?is subsection1 ! violation = :i* su* p5alty 0 impos$1 & su* additional in=mation z ! ,secret>y det]m9es appropriate4 7#b7 ,*ange ( own]%ip ,) respect to a p>ticipat+ hospital t _h a *ange ( own]%ip1 z det]m9$ by ! ,secret>y1 p5alties impos$ on ! hospital :ile "u previ\s own]%ip %all no long] be publi%$ by ! ,secret>y ( su* ,int]net ,web site aft] ! #a-ye> p]iod beg9n+ on ! date ( *ange ( own]%ip4 7f7 ,(fset ,funds collect$ by ! ,secret>y "u ?is section %all be us$ to (fset ! co/s ( en=c+ ?is title4 #cdjg4 ,def9itions ,= purposes ( ?is title3 7#a7 ,acuity sy/em ,! t]m acuity sy/em means an e/abli%$ measurem5t tool t-- 7,a7 pr$icts nurs+ c>e requirem5ts = individual pati5ts bas$ on sev]ity ( pati5t illness1 ne$ = specializ$ equipm5t & te*nology1 int5sity ( nurs+ int]v5tions requir$1 & ! complexity ( cl9ical nurs+ judgm5t ne$$ to design1 implem5t1 & evaluate ! pati5t's nurs+ c>e plan2 7,b7 details ! am\nt ( nurs+ c>e ne$$1 bo? 9 numb] ( nurses & 9 skill mix ( nurs+ p]sonnel requir$1 on a daily basis1 = ea* pati5t 9 a nurs+ dep>tm5t or unit2 7,c7 takes into consid]ation ! pati5t c>e s]vices provid$ n only by regi/]$ nurses b also by direct c>e lic5s$ practical nurses & o!r heal? c>e p]sonnel2 & 7,d7 is /at$ 9 t]ms t c be readily us$ & und]/ood by nurses4 7#b7 ,direct c>e lic5s$ practical nurse ,! t]m direct c>e lic5s$ practical nurse means an individual :o has be5 grant$ a lic5se by at lea/ "o ,/ate to practice z a lic5s$ practical nurse or a lic5s$ vocational nurse & :o provides b$side c>e = "o or m pati5ts4 7#c7 ,direct c>e regi/]$ nurse ,! t]m direct c>e regi/]$ nurse means an individual :o has be5 grant$ a lic5se by at lea/ "o ,/ate to practice z a regi/]$ nurse & :o provides b$side c>e = "o or m pati5ts4 7#d7 ,employm5t ,! t]m employm5t includes ! provision ( s]vices "u a contract or o!r arrangem5t4 7#e7 ,hospital ,! t]m hospital has ! mean+ giv5 t t]m 9 section #ahfa7;e7 ( ! ,social ,security ,act1 & includes a hospital t is op]at$ by ! ,dep>tm5t ( ,vet]ans ,affairs1 ! ,dep>tm5t ( ,def5se1 ! ,indian ,heal? ,s]vices ,program1 or any o!r dep>tm5t or ag5cy ( ! ,unit$ ,/ates4 7#f7 ,nurse ,! t]m nurse means any direct c>e regi/]$ nurse or direct c>e lic5s$ practical nurse 7z ! case may be71 reg>dless ( :e!r or n ! nurse is an employee4 7#g7 ,/aff+ plan ,! t]m /aff+ plan means a /aff+ plan requir$ "u section #cdja4 7#h7 ,/ate ( em]g5cy ,! t]m /ate ( em]g5cy-- 7,a7 means a /ate ( em]g5cy t is an unpr$ictable or unavoidable occurr5ce at an uns*$ul$ or unpr$ictable int]val1 relat+ to heal? c>e deliv]y & requir+ imm$iate m$ical int]v5tions & c>e2 & 7,b7 does n include a /ate em]g5cy t results f a labor dispute 9 ! heal? c>e indu/ry or consi/5t und]/aff+4 #cdjh4 ,rule ( con/ruction ,no?+ 9 ?is title %all be con/ru$ to au?orize disclosure ( private & confid5tial pati5t in=mation1 except 9 ! case :]e su* disclosure is o!rwise requir$ by law1 compell$ by prop] legal process1 cons5t$ to by ! pati5t1 provid$ 9 confid5ce to regulatory or accr$itation ag5cies or o!r gov]nm5t entities = inve/igatory purposes1 or provid$ pursuant to =mal or in=mal compla9ts ( unlawful or improp] practices = purposes ( a*iev+ corrective & rem$ial action4 4 7b7 ,recomm5dations to ,congress ,n lat] ?an #a ye> aft] ! date ( enactm5t ( ?is ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices %all submit to ,congress a report conta9+ recomm5dations = ensur+ t suffici5t numb]s ( nurses are available to meet ! requirem5ts impos$ by title ,,xxxiv ( ! ,public ,heal? ,s]vice ,act1 z add$ by subsection 7a74 7c7 ,report by ,,hrsa 7#a7 ,9 g5]al ,n lat] ?an #b ye>s aft] ! date ( enactm5t ( ?is ,act1 ! ,adm9i/rator ( ! ,heal? ,res\rces & ,s]vices ,adm9i/ration1 9 consultation ) ! ,national ,heal? ,c>e ,work=ce ,commission1 %all submit to ,congress a report reg>d+ ! relation%ip betwe5 nurse /aff+ levels & nurse ret5tion 9 hospitals4 7#b7 ,updat$ report ,n lat] ?an #e ye>s aft] ! date ( enactm5t ( ?is ,act1 ! ,adm9i/rator ( ! ,heal? ,res\rces & ,s]vices ,adm9i/ration1 9 consultation ) ! ,national ,heal? ,c>e ,work=ce ,commission1 %all submit to ,congress an update ( ! report submitt$ "u p>agraph 7#a74 #c4 ,en=cem5t ( requirem5ts ?r\gh ,f$]al programs 7a7 ,m$ic>e program ,section #ahff7;a77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7a77#a77 is am5d$-- 7#a7 by /rik+ & at ! end ( subp>agraph 7,v72 7#b7 9 ! subp>agraph 7,w7 add$ by section #cjje7a77;,c7 ( ,public ,law #aaa-adh-- 7,a7 by /rik+ ! p]iod at ! end & ins]t+ a comma2 7,b7 by mov+ ! ind5tation #b ems to ! left2 & 7,c7 by mov+ su* subp>agraph to imm$iately foll[ subp>agraph 7,v72 7#c7 9 ! subp>agraph 7,w7 add$ by section #fdjf7;b77#c7 ( ,public ,law #aaa-adh-- 7,a7 by /rik+ ! p]iod at ! end & ins]t+ 1 &2 7,b7 by mov+ ! ind5tation #b ems to ! left2 7,c7 by r$esignat+ su* sub>agraph z subp>agraph 7,x72 & 7,d7 by mov+ su* subp>agraph to imm$iately foll[ subp>agraph 7,w71 z mov$ "u p>agraph 7#b77;,c72 & 7#d7 by ins]t+ aft] ! subp>agraph 7,x71 z r$esignat$ & mov$ "u p>agraph 7#c71 ! foll[+3 7,y7 9 ! case ( a hospital1 to comply ) ! provisions ( title ,,xxxiv ( ! ,public ,heal? ,s]vice ,act4 4 7b7 ,m$icaid program ,section #aijb7;a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif7;a77 is am5d$-- 7#a7 by /rik+ & at ! end ( p>agraph 7#hb77;,c72 7#b7 by /rik+ ! p]iod at ! end ( p>agraph 7#hc7 & ins]t+ 2 &2 & 7#c7 by ins]t+ aft] p>agraph 7#hc7 ! foll[+ new p>agraph3 7#hd7 provide t any hospital t receives a paym5t "u su* plan comply ) ! provisions ( title ,,xxxiv ( ! ,public ,heal? ,s]vice ,act 7relat+ to m9imum direct c>e regi/]$ nurse /aff+ requirem5ts74 4 7c7 ,heal? b5efits program ( ! dep>tm5t ( vet]ans affairs ,section #haaj7;a7 ( title #ch1 ,unit$ ,/ates ,code1 is am5d$ by add+ at ! end ! foll[+ new p>agraphs3 7#g7 ,9 ! case ( a ,dep>tm5t m$ical facility t is a hospital1 ! hospital %all comply ) ! provisions ( title ,,xxxiv ( ! ,public ,heal? ,s]vice ,act4 7#h7 ,no?+ ei!r 9 *apt] #gd ( ?is title or 9 section #gajf ( title #e %all preclude en=cem5t ( ! provisions ( title ,,xxxiv ( ! ,public ,heal? ,s]vice ,act ) respect to a ,dep>tm5t hospital ?r\gh grievance proc$ures negotiat$ 9 accordance ) *apt] #ga ( title #e4 4 7d7 ,heal? b5efits program ( ! dep>tm5t ( def5se 7#a7 ,9 g5]al ,*apt] #ee ( title #aj1 ,unit$ ,/ates ,code1 is am5d$ by add+ at ! end ! foll[+ new section3 #aaaj;c4 ,/aff+ requirem5ts ,9 ! case ( a facility ( ! uni=m$ s]vices t is a hospital1 ! hospital %all comply ) ! provisions ( title ,,xxxiv ( ! ,public ,heal? ,s]vice ,act4 4 7#b7 ,cl]ical am5dm5t ,! table ( sections at ! beg9n+ ( su* *apt] is am5d$ by ins]t+ aft] ! item relat+ to section #aaaj;b ! foll[+ new item3 #aaaj;c4 ,/aff+ requirem5ts4 4 7e7 ,indian heal? s]vices program ,title ,,viii ( ! ,indian ,heal? ,c>e ,improvem5t ,act 7#be ,u4,s4,c4 #afga et seq47 is am5d$ by add+ at ! end ! foll[+ new section3 #hcc4 ,/aff+ requirem5ts ,all hospitals ( ! ,s]vice %all comply ) ! provisions ( title ,,xxxiv ( ! ,public ,heal? ,s]vice ,act 7relat+ to m9imum direct c>e regi/]$ nurse /aff+ requirem5ts74 4 7f7 ,f$]al labor-,managem5t relations 7#a7 ,9 g5]al ,section #gajf ( title #e1 ,unit$ ,/ates ,code1 is am5d$ by add+ at ! end ! foll[+3 7c7 ,no?+ 9 ?is section %all preclude en=cem5t ( ! provisions ( title ,,xxxiv ( ! ,public ,heal? ,s]vice ,act ?r\gh grievance proc$ures negotiat$ 9 accordance ) section #gaba4 4 7#b7 ,con=m+ am5dm5t ,section #gajf7;a7 ( title #e1 ,unit$ ,/ates ,code1 is am5d$ by /rik+ ,subject to subsection 7b7 ( ?is title1 & ins]t+ ,subject to subsections 7b7 & 7c714 #d4 ,nurse ,work=ce ,initiative 7a7 ,s*ol>%ip & /ip5d program ,section #hdf7;d7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bign7d77 is am5d$-- 7#a7 9 ! section head+1 by ins]t+ & ,/ip5d aft] ,s*ol>%ip2 & 7#b7 9 p>agraph 7#a71 by ins]t+ or /ip5ds aft] s*ol>%ips4 7b7 ,nurse ret5tion grants ,section #hca;,a7b7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bifp-#a7;b77 is am5d$-- 7#a7 by /rik+ ,grants = ,c>e] ,ladd] ,program4-- & ins]t+ ,grants = ,nurse ,ret5tion4--2 7#b7 9 p>agraph 7#b71 by /rik+ 2 or & ins]t+ a semicolon2 7#c7 9 p>agraph 7#c71 by /rik+ ! p]iod & ins]t+ a semicolon2 & 7#d7 by add+ at ! end ! foll[+3 7#d7 to provide additional support to nurses ent]+ ! work=ce by implem5t+ nurs+ preceptor%ip projects t e/abli% a p]iod ( practical & cl9ical exp]i5ces & tra9+ = nurs+ /ud5ts1 newly hir$ nurses1 & rec5t graduates ( a direct c>e degree programs = regi/]$ nurses2 or 7#e7 to implem5t m5tor%ip projects t assi/ new or transitional direct c>e regi/]$ nurses 9 adapt+ to ! hospital sett+4 4