,,ii  #aac? ,,congress  #a/ ,session    
,s4 #gci  ,,9 ,,! ,,s5ate ,,( ,,!       
,,unit$ ,,/ates  ,april #af1 #bjac ,mrs4
 ,box] introduc$ ! foll[+ bill2 :i* 0   
read twice & ref]r$ to ! ,committee on  
,heal?1 ,education1 ,labor1 & ,p5sions  
,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 title ,?is ,act may
 be cit$ z ! ,national ,nurs+ ,%ortage  
,re=m & ,pati5t ,advocacy ,act4  #b4    
,m9imum direct c>e regi/]$ nurse /aff+  
requirem5ts  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+  
requirem5ts  #cdja4 ,m9imum nurse /aff+ 
requirem5ts  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 o!rwise 
provid$ 9 ?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 %all be assign$
 to n m ?an ! foll[+ numb] ( pati5ts 9 t

 unit1 subject to p>agraph 7#d73  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     
/epd[n units1 p$iatrics units1 telemetry
 units1 antep>tum units1 & comb9$ labor1
 deliv]y1 & po/p>tum units4  7,e7 ,f\r  
pati5ts 9 m$ical-surgical units1        
int]m$iate c>e nurs]y units1 psy*iatric 
units1 & o!r specialty c>e units4  7,f7 
,five pati5ts 9 rehabilitation units1 & 
skill$ nurs+ units4  7,g7 ,six pati5ts 9
 well-baby nurs]y units & po/p>tum 7#c  
c\plets7 units4  7#b7 ,units ) diff]5t  
names ,! ,secret>y may apply m9imum     
direct c>e regi/]$ nurse-to-pati5t      
ratios e/abli%$ 9 p>agraph 7#a7 to a    

type ( hospital unit n ref]r$ to 9 su*  
p>agraph if su* o!r unit provides a     
level ( c>e to pati5ts ^: ne$s are      
simil> to ! ne$s ( pati5ts c>$ = 9 any  
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 ,no   
preemption ( c]ta9 ,/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  7,a7 ,9    
g5]al ,! 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$ical s]vices4  7,b7  
,guidance ,! ,secret>y %all issue       
guidance to hospitals t describes       
situations t con/itute a /ate ( em]g5cy 
= purposes ( ! exemption "u ?is         
p>agraph4  7c7 ,developm5t &            
reevaluation ( /aff+ plan  7#a7         
,consid]ations 9 developm5t ( plan ,9   
develop+ ! /aff+ plan1 a hospital %all  
provide = direct c>e regi/]$            
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 #cdjg7a771 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 & quality ( 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$]al ,labor   
,relations ,act4  7d7 ,acuity tool  7#a7
 ,9 g5]al ,n lat] ?an #b ye>s aft] !    
date ( enactm5t ( ! ,national ,nurs+    
,%ortage ,re=m & ,pati5t ,advocacy ,act1
 ! ,secret>y %all develop a national    
acuity tool t provides a transp>5t me?od
 = e/abli%+ nurse /aff+ requirem5ts     
above ! hospital unit direct c>e regi/]$
 nurse-to-pati5t ratios requir$ "u      
subsection 7b74  7#b7 ,implem5tation    
,ea* hospital may 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    
requir$ "u subsection 7a77#a7 & any     
annual updates "u subsection            
7c77#c77;,b74  #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 #b 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#d71
 7#e77;,a71 & 7#f7 ( 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$ic>e reimbursem5t ,! ,secret>y %all  
adju/ paym5ts made to hospitals "u title
 ,,xviii ( ! ,social ,security ,act 9 an
 am\nt equal to ! net am\nt ( additional
 co/s incurr$ 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$ic>e ,paym5t ,advisory
 ,commission "u subsection 7b74  7b7    
,med,p,a,c report ,n lat] ?an #b ye>s   
aft] ! date ( ! enactm5t ( ?is title1 ! 
,m$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$ic>e paym5ts "u 
subsection 7a74  #cdje4 ,:i/lebl[] &    
pati5t protections  7a7 ,recognition (  
duty & "r ( nurses ,to advocate 9 !     
exclusive int]e/ ( ! pati5t ,a nurse    
%all h ! "r to act z ! pati5t's         
advocate1 z circum/ances require1 by--  
7#a7 initiat+ action to improve heal?   
c>e or to *ange decisions or activities1
 includ+ ! recomm5dations ( heal?       
in=mation te*nology tools1 :i*1 9 !     
pr(essional judgm5t ( ! nurse1 are aga9/
 ! int]e/s & wi%es ( ! pati5t2 &  7#b7  
giv+ ! pati5t an opportunity to make    
in=m$ decisions ab\t heal? c>e be=e x is
 provid$4  7b7 ,refusal ( assignm5t ,a  
nurse may refuse to accept an assignm5t 
z a nurse 9 a hospital if--  7#a7 !     
assignm5t w\ld violate section #cdja or 
#cdjc2 or  7#b7 ! nurse is n prep>$ by  
education1 tra9+1 or exp]i5ce to fulfill
 ! assignm5t )\t compromis+ ! safety (  
any pati5t or jeop>diz+ ! lic5se ( !    
nurse4  7c7 ,retaliation = refusal (    
assignm5t b>r$  7#a7 ,no dis*>ge1       

discrim9ation1 or retaliation ,no       
hospital %all dis*>ge1 discrim9ate1 or  
retaliate 9 any mann] ) respect to any  
aspect ( employm5t 7z def9$ 9 section   
#cdjg7e771 includ+ dis*>ge1 promotion1  
comp5sation1 or t]ms1 conditions1 or    
privileges ( employm5t aga9/ a nurse    
bas$ on ! nurse's refusal ( a "w        
assignm5t "u subsection 7b74  7#b7 ,no  
fil+ ( compla9t ,no hospital %all file a
 compla9t or a report aga9/ a nurse ) ! 
appropriate ,/ate pr(essional discipl9>y
 ag5cy because ( ! nurse's refusal ( a  
"w assignm5t describ$ 9 subsection 7b74 
7d7 ,cause ( action ,any nurse :o has   
be5 dis*>g$1 discrim9at$ aga9/1 or      
retaliat$ aga9/ 9 violation ( subsection
 7c77#a7 or aga9/ :om a compla9t has be5
 fil$ 9 violation ( subsection 7c77#b7  
may 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  7e7 ,compla9t to    
,secret>y  7#a7 ,9 g5]al ,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$1
 issue an ord] t ! compla9+ nurse or    
individual %all n suff] any retaliation 
describ$ 9 subsection 7c7 or subsection 
7g74  7f7 ,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 section #cdja & 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 
7g7 ,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 fai? 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  7h7          

,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$es1 or disc\rages a      
direct c>e regi/]$ nurse f1 or          
intimidates1 co]ces1 or induces a direct
 c>e regi/]$ 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  7i7 ,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 a compla9t "u p>agraph 7#b74 
7j7 ,effective dates  7#a7 ,refusal2    
retaliation2 cause ( action  7,a7 ,9    
g5]al ,subsections 7b7 ?r\gh 7d7 %all   
apply to refusals occurr+ on or aft] !  
effective date ( ! provision to :i* !   

refusal relates4  7,b7 ,exception       
,subsection 7b77#b7 %all n apply to     
refusals 9 any hospital be=e !          
requirem5ts ( section #cdja7;a7 apply to
 t hospital4  7#b7 ,protections =       
report+ ,subsection 7g77#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$+ on or aft] !    
date ( enactm5t ( ?is title4  7#c7      
,notice ,subsection 7i7 %all take effect
 #ah mon?s aft] ! date ( enactm5t ( ?is 
title4  #cdjf4 ,en=cem5t  7a7 ,9 g5]al  
,! ,secret>y %all en=ce ! requirem5ts & 
prohibitions ( ?is title 9 accordance ) 
?is section4  7b7 ,proc$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 website ,!    
,secret>y %all publi% on ! ,int]net     
website ( ! ,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$1 & su* additional   
in=mation z ! ,secret>y det]m9es        
appropriate4  7#b7 ,*ange ( own]%ip ,)  
respect to a p>ticipat+ hospital t _h a 
*ange 9 own]%ip1 z det]m9$ by !         
,secret>y1 p5alties impos$ on ! hospital

 :ile "u previ\s own]%ip %all no long]  
be publi%$ by ! ,secret>y ( su* ,int]net
 website aft] ! #a-ye> p]iod beg9n+ on !
 date ( *ange 9 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/ #a   
,/ate to practice z a lic5s$ practical  
nurse or a lic5s$ vocational nurse & :o 
provides b$side c>e = #a or m pati5ts4  
7#c7 ,direct c>e regi/]$ nurse ,! t]m   
direct c>e regi/]$ nurse means an       
individual :o has be5 grant$ a lic5se by
 at lea/ #a ,/ate to practice z a       
regi/]$ nurse & :o provides b$side c>e =
 #a or m pati5ts4  7#d7 ,employm5t ,!   
t]m employm5t includes ! provision (    
s]vices "u a contract or o!r arrangem5t4
  7#e7 ,hospital ,! t]m hospital has !  
mean+ giv5 t t]m 9 section #ahfa7;e7 ( !
 ,social ,security ,act & includes a    
hospital t is op]at$ by ! ,dep>tm5t (   
,vet]ans ,affairs & a long-t]m c>e      
hospital 7z def9$ 9 section #ahfa7;ccc7 
( su* ,act74  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 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$ical   
int]v5tions & c>e1 b su* t]m does n     
include a /ate ( em]g5cy t results f a  
labor dispute 9 ! heal? c>e indu/ry or  
consi/5t und]/aff+4  #cdjh4 ,rule (     
con/ruction ,no?+ 9 ?is title %all be   
con/ru$ 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$--  7#a7 by   
/rik+ & at ! end ( subp>agraph 7,v72    
7#b7 9 subp>agraph 7,w71 z add$ by      
section #cjje7a77;,c7 ( ! ,pati5t       
,protection & ,af=dable ,c>e ,act       
7,public ,law #aaa-adh7--  7,a7 by mov+ 
su* subp>agraph #b ems to ! left2 &     
7,b7 by /rik+ ! p]iod at ! end & ins]t+ 
a comma2  7#c7 by r$esignat+ subp>agraph
 7,w71 z add$ by section #fdjf7;b77#c7 (
 ! ,pati5t ,protection & ,af=dable ,c>e 
,act 7,public ,law #aaa-adh71 z         
subp>agraph 7,x7 & mov+ su* subp>agraph 
#b ems to ! left2  7#d7 9 subp>agraph   
7,x71 z r$esignat$ by p>agraph 7#c71 by 
/rik+ ! p]iod at ! end & ins]t+ 1 &2 &  
7#e7 by ins]t+ aft] subp>agraph 7,x71 z 
s r$esignat$1 ! foll[+3  7,y7 9 ! case (
 a hospital1 to be subject to !         
provisions ( title ,,xxxiv ( ! ,public  

,heal? ,s]vice ,act4  4  7b7 ,m$icaid   
program ,section #aijb7;a7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4           
#acif;a7a77 is am5d$--  7#a7 9 p>agraph 
7#hb77;,c71 by /rik+ & at ! end2  7#b7 9
 p>agraph 7#hc71 by /rik+ ! p]iod at !  
end & ins]t+ 2 &2 &  7#c7 by ins]t+ aft]
 p>agraph 7#hc7 ! foll[+ new p>agraph3  
7#hd7 provide t any hospital receiv+    
paym5ts "u su* plan %all be subject to !
 provisions ( title ,,xxxiv ( ! ,public 
,heal? ,s]vice ,act4  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[+3  7#g7       
,subject to appropriations1 ! ,secret>y 
( ,vet]ans ,affairs may require t a     
,dep>tm5t m$ical facility t is a        
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 ,au?orization ( appropriations ,!re 
are au?oriz$ to be appropriat$ to !     
,secret>y ( ,vet]ans ,affairs1 =        
compliance ) title ,,xxxiv ( ! ,public  
,heal? ,s]vice ,act pursuant to section 
#haaj7;a77#g7 ( title #ch1 ,unit$ ,/ates
 ,code1 su* sums z may be necess>y =    
fiscal ye> #bjad & ea* subsequ5t fiscal 
ye>4  #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