,,ii  #aafth ,,congress  #ast ,session  
,s4 #aceg  ,,in ,,the ,,senate ,,of     
,,the ,,united ,,states  ,may #h1       
#bjai,mr4 ,brown 7for himself1 ,ms4     
,baldwin1 ,ms4 ,harris1 ,mr4 ,sanders1  
and ,ms4 ,warren7 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 title2     
table of contents2 findings  7a7 ,short 
title ,this ,act may be cited as the    
,nurse ,staffing ,standards for         
,hospital ,patient ,safety and ,quality 
,care ,act of #bjai4  7b7 ,table of     
contents ,the table of contents for this
 ,act is as follows3 ,sec4 #a4 ,short   
title2 table of contents2 findings4,sec4
 #b4 ,minimum direct care registered    
nurse staffing requirement4,sec4 #c4    
,enforcement of requirements through    

,federal programs4,sec4 #d4 ,nurse      
workforce initiative4  7c7 ,findings    
,congress finds the following3 7#a7 ,the
 ,federal ,government has a substantial 
interest in promoting quality care and  
improving the delivery of health care   
services to patients in health care     
facilities in the ,united ,states4  7#b7
 ,recent changes in health care delivery
 systems that have resulted in higher   
acuity levels among patients in health  
care facilities increase the need for   
improved quality measures in order to   
protect patient care and reduce the     
incidence of medical errors4  7#c7      
,inadequate and poorly monitored        
registered nurse staffing practices that
 result in too few registered nurses    
providing direct care jeopardize the    
delivery of quality health care         
services4  7#d7 ,numerous studies have  
shown that patient outcomes are directly
 correlated to direct care registered   
nurse staffing levels1 including a #bjaj
 ,health ,services ,research study that 

concluded that implementation of minimum
 nurse-to-patient staffing ratios in    
,california has led to improved patient 
outcomes and nurse retention and a #bjad
 ,agency for ,healthcare ,research and  
,quality study that concluded increases 
in nurse staffing and skill mix lead to 
improved quality and reduced length of  
stay at no additional cost4  7#e7       
,requirements for direct care registered
 nurse staffing ratios will help address
 the registered nurse shortage in the   
,united ,states by aiding in recruitment
 of new registered nurses and improving 
retention of registered nurses who are  
considering leaving direct patient care 
because of demands created by inadequate
 staffing4  7#f7 ,establishing adequate 
minimum direct care registered          
nurse-to-patient ratios that take into  
account patient acuity measures will    
improve the delivery of quality health  
care services and guarantee patient     
safety4  7#g7 ,establishing safe        
staffing standards for direct care      

registered nurses is a critical         
component of assuring that there is     
adequate hospital staffing at all levels
 to improve the delivery of quality care
 and protect patient safety4  #b4       
,minimum direct care registered nurse   
staffing requirement  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 ,,requirement  #cdja4
 ,minimum nurse staffing requirement    
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 on a date to be determined  
by the ,secretary1 but not later than #a
 year after the date of the 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--  7i7 #b years after the    
date of enactment of this title2 and    
7ii7 in the case of a hospital in a     
rural area 7as defined in section       
#ahhf7;d77#b77;,d7 of the ,social       
,security ,act71 #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 provided in paragraph
 7#d7 and other provisions of this      
section1 a hospital's staffing plan     
shall provide that1 at all times during 
each shift within a unit of the         
hospital1 and with a full complement of 

ancillary and support staff1 a direct   
care registered nurse may be assigned to
 not more than the following number of  
patients in that unit3  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 pediatrics units1 stepdown units1
 telemetry units1 antepartum units1 and 
combined labor1 deliver1 and postpartum 
units4  7,e7 ,four patients in          
medical-surgical units1 intermediate    
care nursery units1 acute care          
psychiatric units1 and other specialty  
care units4  7,f7 ,five patients in     
rehabilitation units and skilled nursing

 units4  7,g7 ,six patients in          
postpartum 7#c couplets7 units and      
well-baby nursery units4  7#b7 ,similar 
units with different names ,the         
,secretary may apply minimum direct care
 registered nurse-to-patient ratios     
established in paragraph 7#a7 for a     
hospital unit referred to in such       
paragraph to a type of hospital unit not
 referred to in such paragraph if such  
type of hospital unit provides a level  
of care to patients whose needs are     
similar to the needs of patients cared  
for in the hospital unit referred to in 
such paragraph4  7#c7 ,application of   
ratios to hospital nursing practice     
standards  7,a7 ,in general ,a patient  
assignment may be included in the       
calculation of the direct care          
registered nurse-to-patient ratios      
required in this subsection only if care
 is provided by a direct care registered
 nurse and the provision of care to the 
particular patient is within that direct
 care registered nurse's competence4    

7,b7 ,demonstration of unit-specific    
competence ,a hospital shall not assign 
a direct care registered nurse to a     
hospital unit unless that hospital      
determines that the direct care         
registered nurse has demonstrated       
current competence in providing care in 
that unit1 and has also received        
orientation to that hospital's unit     
sufficient to provide competent care to 
patients in that unit4  7,c7 ,duties of 
the assigned direct care registered     
nurse ,each patient shall be assigned to
 a direct care registered nurse who     
shall directly provide the assessment1  
planning1 supervision1 implementation1  
and evaluation of the nursing care      
provided to the patient at least every  
shift and has the responsibility for the
 provision of care to a particular      
patient within his or her scope of      
practice4  7,d7 ,nurse administrators   
and supervisors ,a registered nurse who 
is a nurse administrator1 nurse         
supervisor1 nurse manager1 charge nurse1

 case manager1 or any other hospital    
administrator or supervisor1 shall not  
be included in the calculation of the   
direct care registered nurse-to-patient 
ratio unless that nurse has a current   
and active direct patient care          
assignment and provides direct patient  
care in compliance with the requirements
 of this section1 including competency  
requirements4 ,the exemption in this    
subsection shall apply only during the  
hours in which the individual registered
 nurse has the principal responsibility 
of providing direct patient care and has
 no additional job duties as would a    
direct care registered nurse4  7,e7     
,other personnel ,other personnel may   
perform patient care tasks based on     
their training and demonstrated skill   
but may not perform or assist in direct 
care registered nurse functions unless  
authorized to do in accordance with     
,state scope of practice laws and       
regulations4  7,f7 ,temporary nursing   
personnel ,a hospital shall not assign  

any nursing personnel from temporary    
nursing agencies patient care to any    
hospital unit without such personnel    
having demonstrated competence on the   
assigned unit and received orientation  
to that hospital's unit sufficient to   
provide competent care to patients in   
that unit4  7,g7 ,ancillary and         
additional staffing ,the need for       
additional staffing of direct care      
registered nurses1 licensed vocational  
or practical nurses1 licensed           
psychiatric technicians1 certified      
nursing or patient care assistants1 or  
other licensed or unlicensed ancillary  
staff above the minimum registered      
nurse-to-patient ratios shall be based  
on the assessment of the individual     
patient's nursing care requirement1 the 
individual patient's nursing care plan1 
and acuity level4  7#d7 ,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 who has demonstrated   
current competence to the hospital in   
providing care on a particular unit and 
has also received orientation to that   
hospital's unit sufficient to provide   
competent care to patients in that unit 
may relieve another direct care         
registered nurse during breaks1 meals1  
and other routine1 expected absences    
from a hospital unit4  7,d7 ,application
 of direct care registered              
nurse-to-patient ratios in              

patient-acuity adjustable units         
,patients shall be cared for only on    
units or patient care areas where the   
direct care registered nurse-to-patient 
ratios meet the level of intensity1 type
 of care1 and the individual            
requirements and needs of each patient4 
,notwithstanding paragraph 7#b71        
hospitals that provide patient care in  
units or patient care areas that are    
acuity adaptable or acuity adjustable   
shall apply the direct care registered  
nurse-to-patient ratio required in this 
section for the highest patient acuity  
level or level of care in that unit or  
patient care area1 and shall comply with
 all other requirements of this section4
  7,e7 ,use of video monitors ,a        
hospital shall not employ video monitors
 or any form of electronic visualization
 of a patient as a substitute for the   
direct observation required for patient 
assessment by the direct care registered
 nurse or required for patient          
protection4 ,video monitors or any form 

of electronic visualization of a patient
 shall not be included in the           
calculation of the direct care          
registered nurse-to-patient ratio       
required in this subsection and shall   
not replace the requirement of paragraph
 7#c77;,d7 that each patient shall be   
assigned to a direct care registered    
nurse who shall directly provide the    
assessment1 planning1 supervision1      
implementation1 and evaluation of the   
nursing care provided to the patient at 
least every shift and have the          
responsibility for the provision of care
 to a particular patient within his or  
her scope of practice4  7,f7 ,use of    
other technology ,a hospital shall not  
employ technology that substitutes for  
the assigned registered nurse's         
professional judgment in assessment1    
planning1 implementation1 and evaluation
 of care4  7#e7 ,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 reduce 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#f7 ,ancillary and additional 
staffing  7,a7 ,in general ,the         
,secretary may prescribe regulations    
requiring additional staffing of direct 
care registered nurses1 licensed        
vocational or practice nurses1 licensed 
psychiatric technicians1 certified      
nursing or patient care assistants1 or  
other licensed or unlicensed ancillary  
staff above the minimum registered      
nurse-to-patient ratios that is based on
 the assessment of the individual       
patient's nursing care needs1 the       
individual patient's nursing care plan1 

and acuity level4  7,b7 ,consultation   
,such regulations shall be prescribed   
after consultation with affected        
hospitals1 registered nurses1 and       
ancillary staff4  7#g7 ,relationship to 
state-imposed ratios ,nothing in this   
title shall preempt ,state standards    
that the ,secretary determines to be as 
stringent as ,federal requirements for a
 staffing plan established under this   
title4 ,minimum direct care registered  
nurse-to-patient ratios established     
under this subsection shall not preempt 
,state requirements that the ,secretary 
determines are as stringent as to       
,federal requirements for direct care   
registered nurse-to-patient ratios      
established under this title4  7#h7     
,exemption in emergencies ,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 ,if a hospital seeks  

to apply the exemption under this       
paragraph in response to a complaint    
filed against the hospital for a        
violation of the provisions of this     
title1 the hospital must demonstrate    
that prompt and diligent efforts were   
made to maintain required staffing      
levels4 ,the ,secretary shall issue     
guidance to hospitals that describes    
situations that constitute a state of   
emergency for purposes of the exemption 
under this paragraph and shall establish
 necessary penalties for violations of  
this paragraph consistent with section  
#cdjf4  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 of1 at minimum1 the      
following factors3  7,a7 ,the number of 

patients on a particular unit on a      
shift-by-shift basis4  7,b7 ,the acuity 
level and nursing care plan of patients 
on a particular unit on a shift-by-shift
 basis4  7,c7 ,the anticipated          
admissions1 discharges1 and transfers of
 patients during each shift that impacts
 direct patient care4  7,d7 ,specialized
 experience required of direct care     
registered nurses on a particular unit4 
7,e7 ,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,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  7,a7 ,in general  
,a hospital shall annually evaluate its 
staffing plan in each unit in relation  
to actual patient care requirements4    
7,b7 ,update ,a hospital shall update   
its staffing plan to the extent         
appropriate based on such evaluation4   
7#d7 ,transparency  7,a7 ,in general    
,any staffing plan or method used to    
create and evaluate acuity-level and    
adopted by a hospital under this section
 shall be transparent in all respects1  
including disclosure of detailed        
documentation of the methodology used to
 determine 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 7d7 is available for public  
inspection in its entirety4  7#e7       
,registered nurse participation ,a      

staffing plan of a hospital-- 7,a7 shall
 be developed and subsequent            
reevaluations shall be conducted under  
this subsection on the basis of input   
from direct care registered nurses at   
the hospital from each unit or patient  
care area2 and  7,b7 where such nurses  
are represented through collective      
bargaining1 shall require bargaining    
with 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 7#bi   
,u4,s4,c4 #aea et seq47 or chapter #ga  
of title #e1 ,united ,states ,code4     
7#f7 ,staffing committees ,if a hospital
 maintains a staffing committee1 then   
the committee shall include at least one
 registered nurse from each hospital    
unit and shall be composed of at least  
#ej percent direct care registered      
nurses4 ,the staffing committee shall   
include meaningful representation of    

other direct care nonmanagement staff4  
,direct care registered nurses who serve
 on the committee shall be selected by  
other direct care registered nurses from
 their unit4 ,other direct care         
nonmanagement staff shall be selected by
 other direct care nonmanagement staff4 
,participation on staffing committees   
shall be considered a part of the       
employee's regularly scheduled workweek4
  7d7 ,submission of plan to secretary  
,a hospital shall submit to the         
,secretary its staffing plan and any    
annual updates under subsection         
7c77#c77;,b74 ,a federally operated     
hospital may submit its staffing plan   
through the department or agency        
operating the hospital4  #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  7#c7 includes the   
actual number and titles of direct care 
registered nurses assigned during each  
shift2 and  7#d7 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 #c years4  
,such records shall include--  7,a7 the 
number of patients in each unit2  7,b7  
the identity and duty hours of--  7i7   
each direct care registered nurse       
assigned to each patient in each unit in
 each shift2 and  7ii7 ancillary staff  
who are under the coordination of the   
direct care registered nurse2  7,c7     
certification that each nurse received  
rest and meal breaks and the identity   
and duty hours of each direct care      
registered nurse who provided such      
relief2 and  7,d7 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 
the 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 the      
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#d77;,a71 7#d77;,b71 7#d77;,c71 and    

7#f7 of section #cdja7;b71 paragraphs   
7#a71 7#b71 7#c71 and 7#d7 of section   
#cdja7;c71 and section #cdjb shall apply
 to the establishment and application of
 direct care licensed practical nurse   
staffing requirements under this section
 pursuant to the additional staffing    
requirements under subsection           
7b77#c77;,g7 of section #cdja and 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--  7#a7  
#b years after the date of the enactment
 of this title2 and  7#b7 in the case of
 a hospital in a rural area 7as defined 
in section #ahhf7;d77#b77;,d7 of the    
,social ,security ,act71 #d years after 
the date of the enactment of this title4
  7e7 ,study ,not later than #a year    
after the date of the enactment of this 

title1 the ,secretary1 acting through   
the ,director of the ,agency for        
,healthcare ,research and ,quality shall
 complete a study of registered and     
practical nurse staffing requirements in
 clinics and other outpatient settings1 
and its effects on patient care in      
outpatient settings4 ,the ,director may 
contract with a qualified entity or     
organization to carry out such study    
under this subsection4 ,the ,director   
shall consult with registered nurses and
 licensed practice nurses working in    
outpatient settings1 including          
professional nursing associations and   
labor organizations representing both   
registered and practice nurses working  
in outpatient settings regarding the    
design and conduct of the study4  #cdjd4
 ,adjustment in reimbursement  7a7      
,medicare reimbursement ,the ,secretary 
shall adjust payments made to hospitals 
7other than federally operated          
hospitals7 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 7c74  7b7 ,authorization of  
appropriation for federally operated    
hospitals ,there are authorized to be   
appropriated such additional sums as are
 required for federally operated        
hospitals to comply with the additional 
requirements established under sections 
#cdja through #cdjc4  7c7 ,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 ,professional obligation and rights 
,all nurses have a duty and right to act
 based on their professional judgment in
 accordance with ,state nursing laws and
 regulations of the ,state in which the 
direct nursing care is being performed  
and to provide care in the exclusive    
interests of the patients and to act as 
the patient's advocate4  7b7 ,acceptance
 of patient care assignments ,the nurse 
is responsible for providing competent1 
safe1 therapeutic1 and effective nursing
 care to assigned patients4 ,before     
accepting a patient assignment1 a nurse 
shall--  7#a7 have the necessary        
professional knowledge1 judgment1       
skills1 and ability to provide the      

required care2  7#b7 determine using    
professional judgment in accordance with
 ,state nursing laws and regulations of 
the ,state in which the direct nursing  
care is being performed whether the     
nurse is competent to perform the       
nursing care required2 and  7#c7        
determine whether acceptance of a       
patient assignment would expose the     
patient or nurse to risk of harm4  7c7  
,objection to or refusal of assignment  
,a nurse may object to1 or refuse to    
participate in1 any activity1 policy1   
practice1 assignment1 or task if in good
 faith--  7#a7 the nurse reasonably     
believes it to be in violation of       
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  7d7          
,retaliation for objection to or refusal
 of assignment barred  7#a7 ,no         
discharge1 discrimination1 or           

retaliation ,no hospital shall          
discharge1 retaliate1 discriminate1 or  
otherwise take adverse action in any    
manner with respect to any aspect of a  
nurse's employment 7as defined in       
section #cdjg71 including discharge1    
promotion1 compensation1 or terms1      
conditions1 or privileges of employment1
 based on the nurse's refusal of a work 
assignment under subsection 7c74  7#b7  
,no filing of complaint ,no hospital    
shall file a complaint or a report      
against a nurse with a ,state           
professional disciplinary agency because
 of the nurse's refusal of a work       
assignment under subsection 7c74  7e7   
,cause of action ,any nurse1 collective 
bargaining representative1 or legal     
representative of any nurse who has been
 discharged1 discriminated against1 or  
retaliated against in violation of      
subsection 7d77#a7 or against whom a    
complaint or report has been filed in   
violation of subsection 7d77#b7 may     
7without regard to whether a complaint  

has been filed under subsection 7f7 of  
this section or subsection 7b7 of       
section #cdjf7 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  7f7 ,complaint to 
secretary ,a nurse1 patient1 collective 
bargaining representative1 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         
discharge1 retaliation1 discrimination1 

or other adverse action prohibited by   
subsection 7d7 or subsection 7h74  7g7  
,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 through #cdjc 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  7h7 ,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  7i7   
,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 nurse from1 or
 intimidates1 coerces1 or induces a     
direct care 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   
7j7 ,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 such a      
complaint4  7k7 ,effective date  7#a7   
,refusal2 retaliation2 cause of action  
7,a7 ,in general ,subsections 7c7       
through 7e7 shall apply to objections   
and refusals occurring on or after the  
effective date of the provision of this 
title to which the objection or refusal 
relates4  7,b7 ,exception ,subsection   

7c77#b7 shall not apply to objections or
 refusals in any hospital before the    
requirements of section #cdja7;a7 or    
#cdjc7;a71 as applicable1 apply to that 
hospital4  7#b7 ,protections for        
reporting ,subsection 7h77#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 7j7 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 title a civil money   
penalty of--  7i7 not more than #be1jjj 
for the first knowing violation of this 
title by such hospital2 and  7ii7 not   
more than #ej1jjj for any subsequent    
knowing violation of this title by such 
hospital4  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 this title2 and  7ii7         
knowingly violates this title1  a civil 
money penalty of not more than #bj1jjj  
for each such violation by the          
individual4  7#b7 ,procedures ,the      
provisions of section #aabh;,a of the   
,social ,security ,act 7other than      
subsections 7a7 and 7b77 shall apply    
with respect to a civil money penalty or
 proceeding under this subsection in the
 same manner as such provisions apply   
with respect to a civil money penalty or
 proceeding under such section #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 hospitals on     
which a civil money penalty has been    
imposed under this section1 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 hospital that had a  
change of ownership1 as determined by   
the ,secretary1 penalties imposed on the
 hospital while under previous ownership
 shall no longer be published by the    
,secretary pursuant to paragraph 7#a7   
after the #a-year period beginning on   
the date of change of ownership4  7f7   
,use of funds ,funds collected by the   
,secretary pursuant to this section are 
authorized to be appropriated to carry  
out this title4  #cdjg4 ,definitions    
,for purposes of this title3 7#a7       
,acuity level ,the term acuity level    
means the determination1 using a        
hospital acuity measurement tool that   
has been developed and established in   
coordination with direct care registered
 nurses and made transparent pursuant to
 section #cdja7;c77#d71 of nursing care 
requirements1 based on the assigned     
direct care registered nurse's          
professional judgment of--  7,a7 the    

severity and complexity of an individual
 patient's illness or injury2  7,b7 the 
need for specialized equipment2 and     
7,c7 the intensity of nursing           
interventions required4  7#b7           
,competence ,the term competence or     
competent means the satisfactory        
application of the duties and           
responsibilities of a registered nurse  
in providing nursing care to specific   
patient populations and for acuity      
levels for each patient care unit or    
area pursuant to the ,state nursing laws
 and regulations of the ,state in which 
the direct nursing care is being        
performed4  7#c7 ,direct care licensed  
practical nurse ,the term direct care   
licensed practical nurse means an       
individual who has been granted a       
license by at least one ,state to       
practice as a licensed practical nurse  
or a licensed vocational nurse and who  
provides bedside care for one or more   
patients4  7#d7 ,direct care registered 
nurse ,the term direct care registered  

nurse means an individual who has been  
granted a license by at least one ,state
 to practice as a registered nurse and  
who provides bedside care for one or    
more patients4  7#e7 ,employment ,the   
term employment includes the provision  
of services under a contract or other   
arrangement4  7#f7 ,hospital ,the term  
hospital has the meaning given that term
 in section #ahfa7;e7 of the ,social    
,security ,act1 and includes a hospital 
that is operated by the ,department of  
,veterans ,affairs1 the ,department of  
,defense1 the ,indian ,health ,services 
,program1 or any other department or    
agency of the ,united ,states4  7#g7    
,nurse ,the term nurse means any direct 
care registered nurse or direct care    
licensed practice nurse 7as the case may
 be71 regardless of whether or not the  
nurse is an employee4  7#h7 ,nursing    
care plan ,the term nursing care plan   
means a plan developed by the assigned  
direct care registered nurse 7in        
accordance with nursing law in the      

,state in which the nursing care is     
performed7 that indicates the nursing   
care to be given to individual patients 
that--  7,a7 considers the acuity level 
of the patient2  7,b7 is developed in   
coordination with the patient1 the      
patient's family1 or other              
representatives when appropriate1 and   
staff of other disciplines involved in  
the care of the patient2  7,c7 reflects 
all elements of the nursing process2 and
  7,d7 recommends the number and skill  
mix of additional licensed and          
unlicensed direct care staff needed to  
fully implement the nursing care plan4  
7#i7 ,professional judgment ,the term   
professional judgment means1 in         
accordance with ,state nursing laws and 
regulations of the ,state in which the  
direct nursing care is being performed1 
the direct care registered nurse's      
application of knowledge1 expertise1 and
 experience in conducting a             
comprehensive nursing assessment of each
 patient and in making independent      

decisions about patient care including  
the need for additional staff4  7#aj7   
,staffing plan ,the term staffing plan  
means a staffing plan required under    
section #cdja4  7#aa7 ,state of         
emergency ,the term state of emergency--
  7,a7 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     
care2 and  7,b7 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 if such disclosure 
is not authorized or required by other  
applicable law4  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 in   
subparagraph 7,x71 by striking 1 and and
 inserting a comma2  7#b7 in            
subparagraph 7,y71 by striking the      
period at the end and inserting 1 and2  
and  7#c7 by inserting after the        
subparagraph 7,y7 the following new     
subparagraph3  7,z7 in the case of a    
hospital1 to comply with 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 by        
striking and at the end of paragraph    
7#he72  7#b7 by striking the period at  
the end of paragraph 7#hf7 and inserting
 2 and2 and  7#c7 by inserting after    
paragraph 7#hf7 the following new       
paragraph3  7#hg7 provide that any      

hospital that receives a payment under  
such plan comply with the provisions of 
title ,,xxxiv of the ,public ,health    
,service ,act 7relating to minimum      
direct care registered nurse staffing   
requirements74  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 following new     
paragraphs3  7#g7 ,in the case of a     
,department medical facility that is a  
hospital1 the 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 ,health benefits program of 
the department of defense  7#a7 ,in     

general ,chapter #ee of title #aj1      
,united ,states ,code1 is amended by    
adding at the end the following new     
section3  #aaaj;c4 ,staffing            
requirements ,in the case of a facility 
of the uniformed services that is a     
hospital1 the hospital shall comply with
 the provisions of title ,,xxxiv of the 
,public ,health ,service ,act4  4  7#b7 
,clerical amendment ,the table of       
sections at the beginning of such       
chapter is amended by inserting after   
the item relating to section #aaaj;b the
 following new item3  #aaaj;c4 ,staffing
 requirements4  4  7e7 ,indian health   
services program ,title ,,viii of the   
,indian ,health ,care ,improvement ,act 
7#be ,u4,s4,c4 #afga et seq47 is amended
 by adding at the end the following new 
section3  #hcc4 ,staffing requirements  
,all hospitals of the ,service shall    
comply with the provisions of title     
,,xxxiv of the ,public ,health ,service 
,act 7relating to minimum direct care   
registered nurse staffing requirements74

  4  7f7 ,federal labor-,management     
relations  7#a7 ,in general ,section    
#gajf of title #e1 ,united ,states      
,code1 is amended by adding at the end  
the following3  7c7 ,nothing in this    
section shall preclude enforcement of   
the provisions of title ,,xxxiv of the  
,public ,health ,service ,act through   
grievance procedures negotiated in      
accordance with section #gaba4  4  7#b7 
,conforming amendment ,section #gajf7;a7
 of title #e1 ,united ,states ,code1 is 
amended by striking ,subject to         
subsection 7b7 of this title1 and       
inserting ,subject to subsections 7b7   
and 7c714  #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 program 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