,,ii #aacth ,,congress #ast ,session ,s4 #gci ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,april #af1 #bjac ,mrs4 ,boxer introduced the following bill2 which was read twice and referred to the ,committee on ,health1 ,education1 ,labor1 and ,pensions ,a ,,bill ,to amend the ,public ,health ,service ,act to establish direct care registered nurse-to-patient staffing ratio requirements in hospitals1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,national ,nursing ,shortage ,reform and ,patient ,advocacy ,act4 #b4 ,minimum direct care registered nurse staffing requirements 7a7 ,minimum direct care registered nurse staffing requirements ,the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bja et seq47 is amended by adding at the end the following new title3 ,,xxxiv ,minimum direct care registered nurse staffing requirements #cdja4 ,minimum nurse staffing requirements 7a7 ,staffing plan 7#a7 ,in general ,a hospital shall implement a staffing plan that-- 7,a7 provides adequate1 appropriate1 and quality delivery of health care services and protects patient safety2 and 7,b7 is consistent with the requirements of this title4 7#b7 ,effective dates 7,a7 ,implementation of staffing plan ,subject to subparagraph 7,b71 the requirements under paragraph 7#a7 shall take effect not later than #a year after the date of enactment of this title4 7,b7 ,application of minimum direct care registered nurse-to-patient ratios ,the requirements under subsection 7b7 shall take effect as soon as practicable1 as determined by the ,secretary1 but not later than #b years after the date of enactment of this title1 or in the case of a hospital in a rural area 7as defined in section #ahhf7;d77#b77;,d7 of the ,social ,security ,act71 not later than #d years after the date of enactment of this title4 7b7 ,minimum direct care registered nurse-to-,patient ratios 7#a7 ,in general ,except as otherwise provided in this section1 a hospital's staffing plan shall provide that1 at all times during each shift within a unit of the hospital1 a direct care registered nurse shall be assigned to not more than the following number of patients in that unit1 subject to paragraph 7#d73 7,a7 ,one patient in trauma emergency units4 7,b7 ,one patient in operating room units1 provided that a minimum of #a additional person serves as a scrub assistant in such unit4 7,c7 ,two patients in critical care units1 including neonatal intensive care units1 emergency critical care and intensive care units1 labor and delivery units1 coronary care units1 acute respiratory care units1 postanesthesia units1 and burn units4 7,d7 ,three patients in emergency room units1 stepdown units1 pediatrics units1 telemetry units1 antepartum units1 and combined labor1 delivery1 and postpartum units4 7,e7 ,four patients in medical-surgical units1 intermediate care nursery units1 psychiatric units1 and other specialty care units4 7,f7 ,five patients in rehabilitation units1 and skilled nursing units4 7,g7 ,six patients in well-baby nursery units and postpartum 7#c couplets7 units4 7#b7 ,units with different names ,the ,secretary may apply minimum direct care registered nurse-to-patient ratios established in paragraph 7#a7 to a type of hospital unit not referred to in such paragraph if such other unit provides a level of care to patients whose needs are similar to the needs of patients cared for in any unit referred to in such paragraph4 7#c7 ,restrictions 7,a7 ,prohibition against averaging ,a hospital shall not average the number of patients and the total number of direct care registered nurses assigned to patients in a hospital unit during any #a shift or over any period of time for purposes of meeting the requirements under this subsection4 7,b7 ,prohibition against imposition of mandatory overtime requirements ,a hospital shall not impose mandatory overtime requirements to meet the hospital unit direct care registered nurse-to-patient ratios required under this subsection4 7,c7 ,relief during routine absences ,a hospital shall ensure that only a direct care registered nurse may relieve another direct care registered nurse during breaks1 meals1 and other routine1 expected absences from a hospital unit4 7#d7 ,adjustment of ratios 7,a7 ,in general ,if necessary to protect patient safety1 the ,secretary may prescribe regulations that-- 7i7 increase minimum direct care registered nurse-to-patient ratios under this subsection to further limit the number of patients that may be assigned to each direct care nurse2 or 7ii7 add minimum direct care registered nurse-to-patient ratios for units not referred to in paragraphs 7#a7 and 7#b74 7,b7 ,consultation ,such regulations shall be prescribed after consultation with affected hospitals and registered nurses4 7#e7 ,no preemption of certain ,state-imposed ratios ,nothing in this title shall preempt ,state standards that the ,secretary determines to be at least equivalent to ,federal requirements for a staffing plan established under this title4 ,minimum direct care registered nurse-to-patient ratios established under this subsection shall not preempt ,state requirements that the ,secretary determines are at least equivalent to ,federal requirements for a staffing plan established under this title4 7#f7 ,exemption in emergencies 7,a7 ,in general ,the requirements established under this subsection shall not apply during a state of emergency if a hospital is requested or expected to provide an exceptional level of emergency or other medical services4 7,b7 ,guidance ,the ,secretary shall issue guidance to hospitals that describes situations that constitute a state of emergency for purposes of the exemption under this paragraph4 7c7 ,development and reevaluation of staffing plan 7#a7 ,considerations in development of plan ,in developing the staffing plan1 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 7b7 if appropriate based upon consideration of the following factors3 7,a7 ,the number of patients and acuity level of patients as determined by the application of an acuity system 7as defined in section #cdjg7a771 on a shift-by-shift basis4 7,b7 ,the anticipated admissions1 discharges1 and transfers of patients during each shift that impacts direct patient care4 7,c7 ,specialized experience required of direct care registered nurses on a particular unit4 7,d7 ,staffing levels and services provided by licensed vocational or practical nurses1 licensed psychiatric technicians1 certified nurse assistants1 or other ancillary staff in meeting direct patient care needs not required by a direct care registered nurse4 7,e7 ,the level and quality of technology available that affects the delivery of direct patient care4 7,f7 ,the level of familiarity with hospital practices1 policies1 and procedures by temporary agency direct care registered nurses used during a shift4 7,g7 ,obstacles to efficiency in the delivery of patient care presented by physical layout4 7#b7 ,documentation of staffing ,a hospital shall specify the system used to document actual staffing in each unit for each shift4 7#c7 ,annual reevaluation of plan and acuity system 7,a7 ,in general ,a hospital shall annually evaluate-- 7i7 its staffing plan in each unit in relation to actual patient care requirements2 and 7ii7 the accuracy of its acuity system4 7,b7 ,update ,a hospital shall update its staffing plan and acuity system to the extent appropriate based on such evaluation4 7#d7 ,transparency 7,a7 ,in general ,any acuity-based patient classification system adopted by a hospital under this section shall be transparent in all respects1 including disclosure of detailed documentation of the methodology used to predict nursing staffing1 identifying each factor1 assumption1 and value used in applying such methodology4 7,b7 ,public availability ,the ,secretary shall establish procedures to provide that the documentation submitted under subsection 7e7 is available for public inspection in its entirety4 7#e7 ,registered nurse participation ,a staffing plan of a hospital shall be developed and subsequent reevaluations shall be conducted under this subsection on the basis of input from direct care registered nurses at the hospital or1 where such nurses are represented through collective bargaining1 from the applicable recognized or certified collective bargaining representative of such nurses4 ,nothing in this title shall be construed to permit conduct prohibited under the ,national ,labor ,relations ,act or under the ,federal ,labor ,relations ,act4 7d7 ,acuity tool 7#a7 ,in general ,not later than #b years after the date of enactment of the ,national ,nursing ,shortage ,reform and ,patient ,advocacy ,act1 the ,secretary shall develop a national acuity tool that provides a transparent method for establishing nurse staffing requirements above the hospital unit direct care registered nurse-to-patient ratios required under subsection 7b74 7#b7 ,implementation ,each hospital may adopt and implement the national acuity tool described in paragraph 7#a71 and provide staffing based on such tool4 ,any additional direct care registered nursing staffing above the hospital unit direct care registered nurse-to-patient ratios described in subsection 7b7 shall be assigned in a manner determined by such national acuity tool4 7e7 ,submission of plan to ,secretary ,a hospital shall submit to the ,secretary its staffing plan required under subsection 7a77#a7 and any annual updates under subsection 7c77#c77;,b74 #cdjb4 ,posting1 records1 and audits 7a7 ,posting requirements ,in each unit1 a hospital shall post a uniform notice in a form specified by the ,secretary in regulation that-- 7#a7 explains requirements imposed under section #cdja2 7#b7 includes actual direct care registered nurse-to-patient ratios during each shift2 and 7#c7 is visible1 conspicuous1 and accessible to staff1 patients1 and the public4 7b7 ,records 7#a7 ,maintenance of records ,each hospital shall maintain accurate records of actual direct care registered nurse-to-patient ratios in each unit for each shift for no less than #b years4 ,such records shall include-- 7,a7 the number of patients in each unit2 7,b7 the identity and duty hours of each direct care registered nurse assigned to each patient in each unit in each shift2 and 7,c7 a copy of each notice posted under subsection 7a74 7#b7 ,availability of records ,each hospital shall make its records maintained under paragraph 7#a7 available to-- 7,a7 the ,secretary2 7,b7 registered nurses and their collective bargaining representatives 7if any72 and 7,c7 the public under regulations established by the ,secretary1 or in the case of a federally operated hospital1 under section #eeb of title #e1 ,united ,states ,code 7commonly known as the ,freedom of ,information ,act74 7c7 ,audits ,the ,secretary shall conduct periodic audits to ensure-- 7#a7 implementation of the staffing plan in accordance with this title2 and 7#b7 accuracy in records maintained under this section4 #cdjc4 ,minimum direct care licensed practical nurse staffing requirements 7a7 ,establishment ,a hospital's staffing plan shall comply with minimum direct care licensed practical nurse staffing requirements that the ,secretary establishes for units in hospitals4 ,such staffing requirements shall be established not later than #ah months after the date of enactment of this title1 and shall be based on the study conducted under subsection 7b74 7b7 ,study ,not later than #a year after the date of enactment of this title1 the ,secretary1 acting through the ,director of the ,agency for ,healthcare ,research and ,quality1 shall complete a study of licensed practical nurse staffing and its effects on patient care in hospitals4 ,the ,director may contract with a qualified entity or organization to carry out such study under this paragraph4 ,the ,director shall consult with licensed practical nurses and organizations representing licensed practical nurses regarding the design and conduct of the study4 7c7 ,application of registered nurse provisions to licensed practical nurse staffing requirements ,paragraphs 7#b71 7#d71 7#e77;,a71 and 7#f7 of section #cdja7;b71 section #cdja7;c71 and section #cdjb shall apply to the establishment and application of direct care licensed practical nurse staffing requirements under this section in the same manner that they apply to the establishment and application of direct care registered nurse-to-patient ratios under sections #cdja and #cdjb4 7d7 ,effective date ,the requirements of this section shall take effect as soon as practicable1 as determined by the ,secretary1 but not later than #b years after the date of enactment of this title1 or in the case of a hospital in a rural area 7as defined in section #ahhf7;d77#b77;,d7 of the ,social ,security ,act71 not later than #d years after the date of enactment of this title4 #cdjd4 ,adjustment in reimbursement 7a7 ,medicare reimbursement ,the ,secretary shall adjust payments made to hospitals under title ,,xviii of the ,social ,security ,act in an amount equal to the net amount of additional costs incurred in providing services to ,medicare beneficiaries that are attributable to compliance with requirements imposed under sections #cdja through #cdjc4 ,the amount of such payment adjustments shall take into account recommendations contained in the report submitted by the ,medicare ,payment ,advisory ,commission under subsection 7b74 7b7 ,med,p,a,c report ,not later than #b years after the date of the enactment of this title1 the ,medicare ,payment ,advisory ,commission 7established under section #ahje of the ,social ,security ,act7 shall submit to ,congress and the ,secretary a report estimating total costs and savings attributable to compliance with requirements imposed under sections #cdja through #cdjc4 ,such report shall include recommendations on the need1 if any1 to adjust reimbursement for ,medicare payments under subsection 7a74 #cdje4 ,whistleblower and patient protections 7a7 ,recognition of duty and right of nurses ,to advocate in the exclusive interest of the patient ,a nurse shall have the right to act as the patient's advocate1 as circumstances require1 by-- 7#a7 initiating action to improve health care or to change decisions or activities1 including the recommendations of health information technology tools1 which1 in the professional judgment of the nurse1 are against the interests and wishes of the patient2 and 7#b7 giving the patient an opportunity to make informed decisions about health care before it is provided4 7b7 ,refusal of assignment ,a nurse may refuse to accept an assignment as a nurse in a hospital if-- 7#a7 the assignment would violate section #cdja or #cdjc2 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 7c7 ,retaliation for refusal of assignment barred 7#a7 ,no discharge1 discrimination1 or retaliation ,no hospital shall discharge1 discriminate1 or retaliate in any manner with respect to any aspect of employment 7as defined in section #cdjg7e771 including discharge1 promotion1 compensation1 or terms1 conditions1 or privileges of employment against a nurse based on the nurse's refusal of a work assignment under subsection 7b74 7#b7 ,no filing of complaint ,no hospital shall file a complaint or a report against a nurse with the appropriate ,state professional disciplinary agency because of the nurse's refusal of a work assignment described in subsection 7b74 7d7 ,cause of action ,any nurse who has been discharged1 discriminated against1 or retaliated against in violation of subsection 7c77#a7 or against whom a complaint has been filed in violation of subsection 7c77#b7 may bring a cause of action in a ,united ,states district court4 ,a nurse who prevails on the cause of action shall be entitled to one or more of the following3 7#a7 ,reinstatement4 7#b7 ,reimbursement of lost wages1 compensation1 and benefits4 7#c7 ,attorneys' fees4 7#d7 ,court costs4 7#e7 ,other damages4 7e7 ,complaint to ,secretary 7#a7 ,in general ,a nurse1 patient1 or other individual may file a complaint with the ,secretary against a hospital that violates the provisions of this title4 ,for any complaint filed1 the ,secretary shall-- 7,a7 receive and investigate the complaint2 7,b7 determine whether a violation of this title as alleged in the complaint has occurred2 and 7,c7 if such a violation has occurred1 issue an order that the complaining nurse or individual shall not suffer any retaliation described in subsection 7c7 or subsection 7g74 7f7 ,toll-,free telephone number 7#a7 ,in general ,the ,secretary shall provide for the establishment of a toll-free telephone hotline to provide information regarding the requirements under section #cdja and to receive reports of violations of such section4 7#b7 ,notice to patients ,a hospital shall provide each patient admitted to the hospital for inpatient care with the hotline described in paragraph 7#a71 and shall give notice to each patient that such hotline may be used to report inadequate staffing or care4 7g7 ,protection for reporting 7#a7 ,prohibition on retaliation or discrimination ,a hospital shall not discriminate or retaliate in any manner against any patient1 employee1 or contract employee of the hospital1 or any other individual1 on the basis that such individual1 in good faith1 individually or in conjunction with another person or persons1 has presented a grievance or complaint1 or has initiated or cooperated in any investigation or proceeding of any governmental entity1 regulatory agency1 or private accreditation body1 made a civil claim or demand1 or filed an action relating to the care1 services1 or conditions of the hospital or of any affiliated or related facilities4 7#b7 ,good faith defined ,for purposes of this subsection1 an individual shall be deemed to be acting in good faith if the individual reasonably believes-- 7,a7 the information reported or disclosed is true2 and 7,b7 a violation of this title has occurred or may occur4 7h7 ,prohibition on interference with rights 7#a7 ,exercise of rights ,it shall be unlawful for any hospital to-- 7,a7 interfere with1 restrain1 or deny the exercise1 or attempt to exercise1 by any person of any right provided or protected under this title2 or 7,b7 coerce or intimidate any person regarding the exercise or attempt to exercise such right4 7#b7 ,opposition to unlawful policies or practices ,it shall be unlawful for any hospital to discriminate or retaliate against any person for opposing any hospital policy1 practice1 or actions which are alleged to violate1 breach1 or fail to comply with any provision of this title4 7#c7 ,prohibition on interference with protected communications ,a hospital 7or an individual representing a hospital7 shall not make1 adopt1 or enforce any rule1 regulation1 policy1 or practice which in any manner directly or indirectly prohibits1 impedes1 or discourages a direct care registered nurse from1 or intimidates1 coerces1 or induces a direct care registered nurse regarding1 engaging in free speech activities or disclosing information as provided under this title4 7#d7 ,prohibition on interference with collective action ,a hospital 7or an individual representing a hospital7 shall not in any way interfere with the rights of nurses to organize1 bargain collectively1 and engage in concerted activity under section #g of the ,national ,labor ,relations ,act 7#bi ,u4,s4,c4 #aeg74 7i7 ,notice ,a hospital shall post in an appropriate location in each unit a conspicuous notice in a form specified by the ,secretary that-- 7#a7 explains the rights of nurses1 patients1 and other individuals under this section2 7#b7 includes a statement that a nurse1 patient1 or other individual may file a complaint with the ,secretary against a hospital that violates the provisions of this title2 and 7#c7 provides instructions on how to file a complaint under paragraph 7#b74 7j7 ,effective dates 7#a7 ,refusal2 retaliation2 cause of action 7,a7 ,in general ,subsections 7b7 through 7d7 shall apply to refusals occurring on or after the effective date of the provision to which the refusal relates4 7,b7 ,exception ,subsection 7b77#b7 shall not apply to refusals in any hospital before the requirements of section #cdja7;a7 apply to that hospital4 7#b7 ,protections for reporting ,subsection 7g77#a7 shall apply to actions occurring on or after the effective date of the provision to which the violation relates1 except that such subsection shall apply to initiation1 cooperation1 or participation in an investigation or proceeding on or after the date of enactment of this title4 7#c7 ,notice ,subsection 7i7 shall take effect #ah months after the date of enactment of this title4 #cdjf4 ,enforcement 7a7 ,in general ,the ,secretary shall enforce the requirements and prohibitions of this title in accordance with this section4 7b7 ,procedures for receiving and investigating complaints ,the ,secretary shall establish procedures under which-- 7#a7 any person may file a complaint alleging that a hospital has violated a requirement or a prohibition of this title2 and 7#b7 such complaints shall be investigated by the ,secretary4 7c7 ,remedies ,if the ,secretary determines that a hospital has violated a requirement of this title1 the ,secretary-- 7#a7 shall require the facility to establish a corrective action plan to prevent the recurrence of such violation2 and 7#b7 may impose civil money penalties1 as described in subsection 7d74 7d7 ,civil penalties 7#a7 ,in general ,in addition to any other penalties prescribed by law1 the ,secretary may impose civil penalties as follows3 7,a7 ,hospital liability ,the ,secretary may impose on a hospital found to be in violation of this title1 a civil money penalty of not more than #be1jjj for each knowing violation of a requirement of this title1 except that the ,secretary shall impose a civil money penalty of more than #be1jjj 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 ,individual liability ,the ,secretary may impose on an individual who-- 7i7 is employed by a hospital found by the ,secretary to have violated a requirement of this title2 and 7ii7 willfully violates this title1 a civil money penalty of not more than #bj1jjj for each such violation4 7#b7 ,procedures ,the provisions of section #aabh;,a of the ,social ,security ,act 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 such section #aabh;,a4 7e7 ,public notice of violations 7#a7 ,internet website ,the ,secretary shall publish on the ,internet website of the ,department of ,health and ,human ,services the names of participating hospitals on which civil money penalties have been imposed under this subsection1 the violation for which such penalty was imposed1 and such additional information as the ,secretary determines appropriate4 7#b7 ,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 website after the #a-year period beginning on the date of change in ownership4 7f7 ,offset ,funds collected by the ,secretary under this section shall be used to offset the costs of enforcing this title4 #cdjg4 ,definitions ,for purposes of this title3 7#a7 ,acuity system ,the term acuity system means an established measurement tool that-- 7,a7 predicts nursing care requirements for individual patients based on severity of patient illness1 need for specialized equipment and technology1 intensity of nursing interventions required1 and the complexity of clinical nursing judgment needed to design1 implement1 and evaluate the patient's nursing care plan2 7,b7 details the amount of nursing care needed1 both in number of nurses and in skill mix of nursing personnel required1 on a daily basis1 for each patient in a nursing department or unit2 7,c7 takes into consideration the patient care services provided not only by registered nurses but also by direct care licensed practical nurses and other health care personnel2 and 7,d7 is stated in terms that can be readily used and understood by nurses4 7#b7 ,direct care licensed practical nurse ,the term direct care licensed practical nurse means an individual who has been granted a license by at least #a ,state to practice as a licensed practical nurse or a licensed vocational nurse and who provides bedside care for #a or more patients4 7#c7 ,direct care registered nurse ,the term direct care registered nurse means an individual who has been granted a license by at least #a ,state to practice as a registered nurse and who provides bedside care for #a or more patients4 7#d7 ,employment ,the term employment includes the provision of services under a contract or other arrangement4 7#e7 ,hospital ,the term hospital has the meaning given that term in section #ahfa7;e7 of the ,social ,security ,act and includes a hospital that is operated by the ,department of ,veterans ,affairs and a long-term care hospital 7as defined in section #ahfa7;ccc7 of such ,act74 7#f7 ,nurse ,the term nurse means any direct care registered nurse or direct care licensed practical nurse 7as the case may be71 regardless of whether or not the nurse is an employee4 7#g7 ,staffing plan ,the term staffing plan means a staffing plan required under section #cdja4 7#h7 ,state of emergency ,the term state of emergency means a state of emergency that is an unpredictable or unavoidable occurrence at an unscheduled or unpredictable interval1 relating to health care delivery and requiring immediate medical interventions and care1 but such term does not include a state of emergency that results from a labor dispute in the health care industry or consistent understaffing4 #cdjh4 ,rule of construction ,nothing in this title shall be construed to authorize disclosure of private and confidential patient information1 except in the case where such disclosure is otherwise required by law1 compelled by proper legal process1 consented to by the patient1 provided in confidence to regulatory or accreditation agencies or other government entities for investigatory purposes1 or provided pursuant to formal or informal complaints of unlawful or improper practices for purposes of achieving corrective and remedial action4 4 7b7 ,recommendations to ,congress ,not later than #a year after the date of enactment of this ,act1 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 ,act1 as added by subsection 7a74 7c7 ,report by ,,hrsa 7#a7 ,in general ,not later than #b years after the date of enactment of this ,act1 the ,administrator of the ,health ,resources and ,services ,administration1 in consultation with the ,national ,health ,care ,workforce ,commission1 shall submit to ,congress a report regarding the relationship between nurse staffing levels and nurse retention in hospitals4 7#b7 ,updated report ,not later than #e years after the date of enactment of this ,act1 the ,administrator of the ,health ,resources and ,services ,administration1 in consultation with the ,national ,health ,care ,workforce ,commission1 shall submit to ,congress an update of the report submitted under paragraph 7#a74 #c4 ,enforcement of requirements through ,federal programs 7a7 ,medicare program ,section #ahff7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7a77#a77 is amended-- 7#a7 by striking and at the end of subparagraph 7,v72 7#b7 in subparagraph 7,w71 as added by section #cjje7a77;,c7 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 end and inserting a comma2 7#c7 by redesignating subparagraph 7,w71 as added by section #fdjf7;b77#c7 of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh71 as subparagraph 7,x7 and moving such subparagraph #b ems to the left2 7#d7 in subparagraph 7,x71 as redesignated by paragraph 7#c71 by striking the period at the end and inserting 1 and2 and 7#e7 by inserting after subparagraph 7,x71 as so redesignated1 the following3 7,y7 in the case of a hospital1 to be subject to the provisions of title ,,xxxiv of the ,public ,health ,service ,act4 4 7b7 ,medicaid program ,section #aijb7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77 is amended-- 7#a7 in paragraph 7#hb77;,c71 by striking and at the end2 7#b7 in paragraph 7#hc71 by striking the period at the end and inserting 2 and2 and 7#c7 by inserting after paragraph 7#hc7 the following new paragraph3 7#hd7 provide that any hospital receiving payments under such plan shall be subject to the provisions of title ,,xxxiv of the ,public ,health ,service ,act4 4 7c7 ,health ,benefits ,program of the ,department of ,veterans ,affairs ,section #haaj7;a7 of title #ch1 ,united ,states ,code1 is amended by adding at the end the following3 7#g7 ,subject to appropriations1 the ,secretary of ,veterans ,affairs may require that a ,department medical facility that is a hospital shall comply with the provisions of title ,,xxxiv of the ,public ,health ,service ,act4 7#h7 ,nothing either in chapter #gd of this title or in section #gajf of title #e shall preclude enforcement of the provisions of title ,,xxxiv of the ,public ,health ,service ,act with respect to a ,department hospital through grievance procedures negotiated in accordance with chapter #ga of title #e4 4 7d7 ,authorization of appropriations ,there are authorized to be appropriated to the ,secretary of ,veterans ,affairs1 for compliance with title ,,xxxiv of the ,public ,health ,service ,act pursuant to section #haaj7;a77#g7 of title #ch1 ,united ,states ,code1 such sums as may be necessary for fiscal year #bjad and each subsequent fiscal year4 #d4 ,nurse ,workforce ,initiative 7a7 ,scholarship and stipend program ,section #hdf7;d7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bign7d77 is amended-- 7#a7 in the section heading1 by inserting and ,stipend after ,scholarship2 and 7#b7 in paragraph 7#a71 by inserting or stipends after scholarships4 7b7 ,nurse retention grants ,section #hca;,a7b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bifp-#a7;b77 is amended-- 7#a7 by striking ,grants for ,career ,ladder ,program4-- and inserting ,grants for ,nurse ,retention4--2 7#b7 in paragraph 7#b71 by striking 2 or and inserting a semicolon2 7#c7 in paragraph 7#c71 by striking the period and inserting a semicolon2 and 7#d7 by adding at the end the following3 7#d7 to provide additional support to nurses entering the workforce by implementing nursing preceptorship projects that establish a period of practical and clinical experiences and training for nursing students1 newly hired nurses1 and recent graduates of a direct care degree programs for registered nurses2 or 7#e7 to implement mentorship projects that assist new or transitional direct care registered nurses in adapting to the hospital setting4 4