,,ii  #aah? ,,congress  #a/ ,session    
,s4 #aaac  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,m>* #cj1 #bjbc,mr4    
,br[n 7= himself1 ,ms4 ,baldw91 ,ms4    
,w>r51 ,mr4 ,padilla1 ,ms4 ,/ab5[1 ,mr4 
,m>key1 & ,mr4 ,s&]s7 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 title2 table (
 cont5ts2 f9d+s  7a7 ,%ort title ,?is   
,act may be cit$ z ! ,nurse ,/aff+      
,/&>ds = ,hospital ,pati5t ,safety &    
,quality ,c>e ,act ( #bjbc4  7b7 ,table 
( cont5ts ,! table ( cont5ts = ?is ,act 
is z foll[s3 ,sec4 #a4 ,%ort title2     
table ( cont5ts2 f9d+s4,sec4 #b4 ,m9imum
 direct c>e regi/]$ nurse /aff+         
requirem5t4,sec4 #c4 ,en=cem5t (        
requirem5ts ?r\gh ,f$]al programs4,sec4 
#d4 ,nurse work=ce initiative4  7c7     
,f9d+s ,congress f9ds ! foll[+3 7#a7 ,! 

,f$]al ,gov]nm5t has a sub/antial int]e/
 9 promot+ quality c>e & improv+ !      
deliv]y ( heal? c>e s]vices to pati5ts 9
 heal? c>e facilities 9 ! ,unit$ ,/ates4
  7#b7 ,rec5t *anges 9 heal? c>e deliv]y
 sy/ems t h result$ 9 high] acuity      
levels among pati5ts 9 heal? c>e        
facilities increase ! ne$ = improv$     
quality measures 9 ord] to protect      
pati5t c>e & r$uce ! incid5ce ( m$ical  
errors4  7#c7 ,inadequate & poorly      
monitor$ regi/]$ nurse /aff+ practices t
 result 9 too few regi/]$ nurses provid+
 direct c>e jeop>dize ! deliv]y (       
quality heal? c>e s]vices4  7#d7 ,num]\s
 /udies h %[n t pati5t outcomes are     
directly correlat$ to direct c>e regi/]$
 nurse /aff+ levels1 includ+ a #bjaj    
,heal? ,s]vices ,rese>* /udy t conclud$ 
t implem5tation ( m9imum nurse-to-pati5t
 /aff+ ratios 9 ,cali=nia has l$ to     
improv$ pati5t outcomes & nurse ret5tion
 & a #bjad ,ag5cy = ,heal?c>e ,rese>* & 
,quality /udy t conclud$ increases 9    
nurse /aff+ & skill mix lead to improv$ 

quality & r$uc$ l5g? ( /ay at no        
additional co/4  7#e7 ,requirem5ts =    
direct c>e regi/]$ nurse /aff+ ratios w 
help address ! regi/]$ nurse %ortage 9 !
 ,unit$ ,/ates by aid+ 9 recruitm5t (   
new regi/]$ nurses & improv+ ret5tion ( 
regi/]$ nurses :o are consid]+ leav+    
direct pati5t c>e because ( dem&s creat$
 by inadequate /aff+4  7#f7 ,e/abli%+   
adequate m9imum direct c>e regi/]$      
nurse-to-pati5t ratios t take into      
acc\nt pati5t acuity measures w improve 
! deliv]y ( quality heal? c>e s]vices & 
gu>antee pati5t safety4  7#g7 ,e/abli%+ 
safe /aff+ /&>ds = direct c>e regi/]$   
nurses is a critical compon5t ( assur+ t
 !re is adequate hospital /aff+ at all  
levels to improve ! deliv]y ( quality   
c>e & protect pati5t safety4  #b4       
,m9imum direct c>e regi/]$ nurse /aff+  
requirem5t  7a7 ,m9imum direct c>e      
regi/]$ nurse /aff+ requirem5ts ,!      
,public ,heal? ,s]vice ,act 7#db        
,u4,s4,c4 #bja et seq47 is am5d$ by add+
 at ! end ! foll[+ new title3  ,,xxxiv  

,,m9imum ,,direct ,,c>e ,,regi/]$       
,,nurse ,,/aff+ ,,requirem5t  #cdja4    
,m9imum nurse /aff+ requirem5t  7a7     
,/aff+ plan  7#a7 ,9 g5]al ,a hospital  
%all implem5t a /aff+ plan t-- 7,a7     
provides adequate1 appropriate1 &       
quality deliv]y ( heal? c>e s]vices &   
protects pati5t safety2 &  7,b7 is      
consi/5t ) ! requirem5ts ( ?is title4   
7#b7 ,effective dates  7,a7             
,implem5tation ( /aff+ plan ,subject to 
subp>agraph 7,b71 ! requirem5ts "u      
p>agraph 7#a7 %all take effect on a date
 to be det]m9$ by ! ,secret>y1 b 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-- 
7i7 #b ye>s aft] ! date ( enactm5t ( ?is
 title2 &  7ii7 9 ! case ( a hospital 9 
a rural area 7z def9$ 9 section         
#ahhf7;d77#b77;,d7 ( ! ,social ,security
 ,act71 #d ye>s aft] ! date ( enactm5t (

 ?is title4  7b7 ,m9imum direct c>e     
regi/]$ nurse-to-,pati5t ratios  7#a7 ,9
 g5]al ,except z provid$ 9 p>agraph 7#d7
 & o!r provisions ( ?is section1 a      
hospital's /aff+ plan %all provide t1 at
 all times dur+ ea* %ift )9 a unit ( !  
hospital1 & ) a full complem5t (        
ancill>y & support /aff1 a direct c>e   
regi/]$ nurse may be assign$ to n m ?an 
! foll[+ numb] ( pati5ts 9 t unit3 7,a7 
,"o pati5t 9 trauma em]g5cy units4  7,b7
 ,"o pati5t 9 op]at+ room units1 provid$
 t a m9imum ( #a additional p]son s]ves 
z a scrub assi/ant 9 su* unit4  7,c7    
,two pati5ts 9 critical c>e units1      
includ+ neonatal int5sive c>e units1    
em]g5cy critical c>e & int5sive c>e     
units1 labor & deliv]y units1 coron>y   
c>e units1 acute respiratory c>e units1 
po/ane/hesia units1 & burn units4  7,d7 
,?ree pati5ts 9 em]g5cy room units1     
p$iatrics units1 /epd[n units1 telemetry
 units1 antep>tum units1 & comb9$ labor1
 deliv]1 & po/p>tum units4  7,e7 ,f\r   
pati5ts 9 m$ical-surgical units1        

int]m$iate c>e nurs]y units1 acute c>e  
psy*iatric units1 & o!r specialty c>e   
units4  7,f7 ,five pati5ts 9            
rehabilitation units & skill$ nurs+     
units4  7,g7 ,six pati5ts 9 po/p>tum 7#c
 c\plets7 units & well-baby nurs]y      
units4  7#b7 ,simil> units ) diff]5t    
names ,! ,secret>y may apply m9imum     
direct c>e regi/]$ nurse-to-pati5t      
ratios e/abli%$ 9 p>agraph 7#a7 = a     
hospital unit ref]r$ to 9 su* p>agraph  
to a type ( hospital unit n ref]r$ to 9 
su* p>agraph if su* type ( hospital unit
 provides a level ( c>e to pati5ts ^:   
ne$s are simil> to ! ne$s ( pati5ts c>$ 
= 9 ! hospital unit ref]r$ to 9 su*     
p>agraph4  7#c7 ,application ( ratios to
 hospital nurs+ practice /&>ds  7,a7 ,9 
g5]al ,a pati5t assignm5t may be includ$
 9 ! calculation ( ! direct c>e regi/]$ 
nurse-to-pati5t ratios requir$ 9 ?is    
subsection only if c>e is provid$ by a  
direct c>e regi/]$ nurse & ! provision (
 c>e to ! p>ticul> pati5t is )9 t direct
 c>e regi/]$ nurse's compet5ce4  7,b7   

,demon/ration ( unit-specific compet5ce 
,a hospital %all n assign a direct c>e  
regi/]$ nurse to a hospital unit unless 
t hospital det]m9es t ! direct c>e      
regi/]$ nurse has demon/rat$ curr5t     
compet5ce 9 provid+ c>e 9 t unit1 & has 
also receiv$ ori5tation to t hospital's 
unit suffici5t to provide compet5t c>e  
to pati5ts 9 t unit4  7,c7 ,duties ( !  
assign$ direct c>e regi/]$ nurse ,ea*   
pati5t %all be assign$ to a direct c>e  
regi/]$ nurse :o %all directly provide !
 assessm5t1 plann+1 sup]vision1         
implem5tation1 & evaluation ( ! nurs+   
c>e provid$ to ! pati5t at lea/ e %ift &
 has ! responsibility = ! provision (   
c>e to a p>ticul> pati5t )9 8 or h]     
scope ( practice4  7,d7 ,nurse          
adm9i/rators & sup]visors ,a regi/]$    
nurse :o is a nurse adm9i/rator1 nurse  
sup]visor1 nurse manag]1 *>ge nurse1    
case manag]1 or any o!r hospital        
adm9i/rator or sup]visor1 %all n be     
includ$ 9 ! calculation ( ! direct c>e  
regi/]$ nurse-to-pati5t ratio unless t  

nurse has a curr5t & active direct      
pati5t c>e assignm5t & provides direct  
pati5t c>e 9 compliance ) ! requirem5ts 
( ?is section1 includ+ compet5cy        
requirem5ts4 ,! exemption 9 ?is         
subsection %all apply only dur+ ! h\rs 9
 :i* ! individual regi/]$ nurse has !   
pr9cipal responsibility ( provid+ direct
 pati5t c>e & has no additional job     
duties z w\ld a direct c>e regi/]$      
nurse4  7,e7 ,o!r p]sonnel ,o!r p]sonnel
 may p]=m pati5t c>e tasks bas$ on _!   
tra9+ & demon/rat$ skill b may n p]=m or
 assi/ 9 direct c>e regi/]$ nurse       
functions unless au?oriz$ to d 9        
accordance ) ,/ate scope ( practice laws
 & regulations4  7,f7 ,tempor>y nurs+   
p]sonnel ,a hospital %all n assign any  
nurs+ p]sonnel f tempor>y nurs+ ag5cies 
pati5t c>e to any hospital unit )\t su* 
p]sonnel hav+ demon/rat$ compet5ce on ! 
assign$ unit & receiv$ ori5tation to t  
hospital's unit suffici5t to provide    
compet5t c>e to pati5ts 9 t unit4  7,g7 
,ancill>y & additional /aff+ ,! ne$ =   

additional /aff+ ( direct c>e regi/]$   
nurses1 lic5s$ vocational or practical  
nurses1 lic5s$ psy*iatric te*nicians1   
c]tifi$ nurs+ or pati5t c>e assi/ants1  
or o!r lic5s$ or unlic5s$ ancill>y /aff 
above ! m9imum regi/]$ nurse-to-pati5t  
ratios %all be bas$ on ! assessm5t ( !  
individual pati5t's nurs+ c>e           
requirem5t1 ! individual pati5t's nurs+ 
c>e plan1 & acuity level4  7#d7         
,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 :o has        

demon/rat$ curr5t compet5ce to !        
hospital 9 provid+ c>e on a p>ticul>    
unit & has also receiv$ ori5tation to t 
hospital's unit suffici5t to provide    
compet5t c>e to pati5ts 9 t unit may    
relieve ano!r direct c>e regi/]$ nurse  
dur+ breaks1 meals1 & o!r r\t9e1 expect$
 abs5ces f a hospital unit4  7,d7       
,application ( direct c>e regi/]$       
nurse-to-pati5t ratios 9 pati5t-acuity  
adju/able units ,pati5ts %all be c>$ =  
only on units or pati5t c>e areas :]e ! 
direct c>e regi/]$ nurse-to-pati5t      
ratios meet ! level ( int5sity1 type (  
c>e1 & ! individual requirem5ts & ne$s (
 ea* pati5t4 ,not)/&+ p>agraph 7#b71    
hospitals t provide pati5t c>e 9 units  
or pati5t c>e areas t are acuity        
adaptable or acuity adju/able %all apply
 ! direct c>e regi/]$ nurse-to-pati5t   
ratio requir$ 9 ?is section = ! highe/  
pati5t acuity level or level ( c>e 9 t  
unit or pati5t c>e area1 & %all comply )
 all o!r requirem5ts ( ?is section4     
7,e7 ,use ( video monitors ,a hospital  

%all n employ video monitors or any =m (
 electronic visualization ( a pati5t z a
 sub/itute = ! direct obs]vation requir$
 = pati5t assessm5t by ! direct c>e     
regi/]$ nurse or requir$ = pati5t       
protection4 ,video monitors or any =m ( 
electronic visualization ( a pati5t %all
 n be includ$ 9 ! calculation ( ! direct
 c>e regi/]$ nurse-to-pati5t ratio      
requir$ 9 ?is subsection & %all n       
replace ! requirem5t ( p>agraph         
7#c77;,d7 t ea* pati5t %all be assign$  
to a direct c>e regi/]$ nurse :o %all   
directly provide ! assessm5t1 plann+1   
sup]vision1 implem5tation1 & evaluation 
( ! nurs+ c>e provid$ to ! pati5t at    
lea/ e %ift & h ! responsibility = !    
provision ( c>e to a p>ticul> pati5t )9 
8 or h] scope ( practice4  7,f7 ,use (  
o!r te*nology ,a hospital %all n employ 
te*nology t sub/itutes = ! assign$      
regi/]$ nurse's pr(essional judgm5t 9   
assessm5t1 plann+1 implem5tation1 &     
evaluation ( c>e4  7#e7 ,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 r$uce ! numb] ( pati5ts t may be    
assign$ 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#f7       
,ancill>y & additional /aff+  7,a7 ,9   
g5]al ,! ,secret>y may prescribe        
regulations requir+ additional /aff+ (  
direct c>e regi/]$ nurses1 lic5s$       
vocational or practice nurses1 lic5s$   
psy*iatric te*nicians1 c]tifi$ nurs+ or 
pati5t c>e assi/ants1 or o!r lic5s$ or  
unlic5s$ ancill>y /aff above ! m9imum   
regi/]$ nurse-to-pati5t ratios t is bas$
 on ! assessm5t ( ! individual pati5t's 
nurs+ c>e ne$s1 ! individual pati5t's   
nurs+ c>e plan1 & acuity level4  7,b7   
,consultation ,su* regulations %all be  

prescrib$ aft] consultation ) affect$   
hospitals1 regi/]$ nurses1 & ancill>y   
/aff4  7#g7 ,relation%ip to /ate-impos$ 
ratios ,no?+ 9 ?is title %all preempt   
,/ate /&>ds t ! ,secret>y det]m9es to be
 z /r+5t z ,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 z /r+5t z to ,f$]al       
requirem5ts = direct c>e regi/]$        
nurse-to-pati5t ratios e/abli%$ "u ?is  
title4  7#h7 ,exemption 9 em]g5cies ,!  
requirem5ts e/abli%$ "u ?is subsection  
%all n apply dur+ a /ate ( em]g5cy if a 
hospital is reque/$ or expect$ to       
provide an exceptional level ( em]g5cy  
or o!r m$ical s]vices4 ,if a hospital   
seeks to apply ! exemption "u ?is       
p>agraph 9 response to a compla9t fil$  
aga9/ ! hospital = a violation ( !      
provisions ( ?is title1 ! hospital mu/  
demon/rate t prompt & dilig5t ef=ts 7   
made to ma9ta9 requir$ /aff+ levels4 ,! 

,secret>y %all issue guidance to        
hospitals t describes situations t      
con/itute a /ate ( em]g5cy = purposes ( 
! exemption "u ?is p>agraph & %all      
e/abli% necess>y p5alties = violations (
 ?is p>agraph consi/5t ) section #cdjf4 
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 (1 at m9imum1 ! foll[+     
factors3 7,a7 ,! numb] ( pati5ts on a   
p>ticul> unit on a %ift-by-%ift basis4  
7,b7 ,! acuity level & nurs+ c>e plan ( 
pati5ts on a p>ticul> unit on a         
%ift-by-%ift basis4  7,c7 ,! anticipat$ 
admissions1 dis*>ges1 & transf]s (      
pati5ts dur+ ea* %ift t impacts direct  
pati5t c>e4  7,d7 ,specializ$ exp]i5ce  
requir$ ( direct c>e regi/]$ nurses on a
 p>ticul> unit4  7,e7 ,/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,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 
7,a7 ,9 g5]al ,a hospital %all annually 
evaluate its /aff+ plan 9 ea* unit 9    
relation to actual pati5t c>e           
requirem5ts4  7,b7 ,update ,a hospital  
%all update its /aff+ plan to ! ext5t   
appropriate bas$ on su* evaluation4     
7#d7 ,transp>5cy  7,a7 ,9 g5]al ,any    
/aff+ plan or me?od us$ to create &     
evaluate acuity-level & adopt$ by a     
hospital "u ?is section %all be         

transp>5t 9 all respects1 includ+       
disclosure ( detail$ docum5tation ( !   
me?odology us$ to det]m9e 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 7d7 
is available = public inspection 9 its  
entirety4  7#e7 ,regi/]$ nurse          
p>ticipation ,a /aff+ plan ( a          
hospital-- 7,a7 %all be develop$ &      
subsequ5t reevaluations %all be conduct$
 "u ?is subsection on ! basis ( input f 
direct c>e regi/]$ nurses at ! hospital 
f ea* unit or pati5t c>e area2 &  7,b7  
:]e su* nurses are repres5t$ ?r\gh      
collective b>ga9+1 %all require b>ga9+ )
 ! 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 7#bi   
,u4,s4,c4 #aea et seq47 or *apt] #ga (  
title #e1 ,unit$ ,/ates ,code4  7#f7    

,/aff+ committees ,if a hospital ma9ta9s
 a /aff+ committee1 !n ! committee %all 
include at lea/ "o regi/]$ nurse f ea*  
hospital unit & %all be compos$ ( at    
lea/ #ej p]c5t direct c>e regi/]$       
nurses4 ,! /aff+ committee %all include 
mean+ful repres5tation ( o!r direct c>e 
nonmanagem5t /aff4 ,direct c>e regi/]$  
nurses :o s]ve on ! committee %all be   
select$ by o!r direct c>e regi/]$ nurses
 f _! unit4 ,o!r direct c>e nonmanagem5t
 /aff %all be select$ by o!r direct c>e 
nonmanagem5t /aff4 ,p>ticipation on     
/aff+ committees %all be consid]$ a "p (
 ! employee's regul>ly s*$ul$ workweek4 
7d7 ,submission ( plan to secret>y ,a   
hospital %all submit to ! ,secret>y its 
/aff+ plan & any annual updates "u      
subsection 7c77#c77;,b74 ,a f$]ally     
op]at$ hospital may submit its /aff+    
plan ?r\gh ! dep>tm5t or ag5cy op]at+ ! 
hospital4  #cdjb4 ,po/+1 records1 &     
audits  7a7 ,po/+ requirem5ts ,9 ea*    
unit1 a hospital %all po/ a uni=m notice
 9 a =m specifi$ by ! ,secret>y 9       

regulation t-- 7#a7 expla9s requirem5ts 
impos$ "u section #cdja2  7#b7 includes 
actual direct c>e regi/]$               
nurse-to-pati5t ratios dur+ ea* %ift2   
7#c7 includes ! actual numb] & titles ( 
direct c>e regi/]$ nurses assign$ dur+  
ea* %ift2 &  7#d7 is visible1           
conspicu\s1 & accessible to /aff1       
pati5ts1 & ! public4  7b7 ,records  7#a7
 ,ma9t5ance ( records ,ea* hospital %all
 ma9ta9 accurate records ( actual direct
 c>e regi/]$ nurse-to-pati5t ratios 9   
ea* unit = ea* %ift = no less ?an #c    
ye>s4 ,su* records %all include-- 7,a7 !
 numb] ( pati5ts 9 ea* unit2  7,b7 !    
id5tity & duty h\rs (-- 7i7 ea* direct  
c>e regi/]$ nurse assign$ to ea* pati5t 
9 ea* unit 9 ea* %ift2 &  7ii7 ancill>y 
/aff :o are "u ! coord9ation ( ! direct 
c>e regi/]$ nurse2  7,c7 c]tification t 
ea* nurse receiv$ re/ & meal breaks & ! 
id5tity & duty h\rs ( ea* direct c>e    
regi/]$ nurse :o provid$ su* relief2 &  
7,d7 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#d77;,a71 
7#d77;,b71 7#d77;,c71 & 7#f7 ( section  
#cdja7;b71 p>agraphs 7#a71 7#b71 7#c71 &
 7#d7 ( section #cdja7;c71 & section    
#cdjb %all apply to ! e/abli%m5t &      
application ( direct c>e lic5s$         
practical nurse /aff+ requirem5ts "u ?is
 section pursuant to ! additional /aff+ 
requirem5ts "u subsection 7b77#c77;,g7 (
 section #cdja & 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-- 7#a7 #b ye>s aft] ! date (
 ! enactm5t ( ?is title2 &  7#b7 9 !    
case ( a hospital 9 a rural area 7z     
def9$ 9 section #ahhf7;d77#b77;,d7 ( !  
,social ,security ,act71 #d ye>s aft] ! 
date ( ! enactm5t ( ?is title4  7e7     
,/udy ,n lat] ?an #a ye> aft] ! date ( !
 enactm5t ( ?is title1 ! ,secret>y1 act+
 ?r\gh ! ,director ( ! ,ag5cy =         
,heal?c>e ,rese>* & ,quality %all       
complete a /udy ( regi/]$ & practical   
nurse /aff+ requirem5ts 9 cl9ics & o!r  
outpati5t sett+s1 & its effects on      
pati5t c>e 9 outpati5t sett+s4 ,!       
,director may contract ) a qualifi$     
entity or organization to c>ry out su*  
/udy "u ?is subsection4 ,! ,director    
%all consult ) regi/]$ nurses & lic5s$  
practice nurses work+ 9 outpati5t       

sett+s1 includ+ pr(essional nurs+       
associations & labor organizations      
repres5t+ bo? regi/]$ & practice nurses 
work+ 9 outpati5t sett+s reg>d+ ! design
 & conduct ( ! /udy4  #cdjd4 ,adju/m5t 9
 reimbursem5t  7a7 ,m$ic>e reimbursem5t 
,! ,secret>y %all adju/ paym5ts made to 
hospitals 7o!r ?an f$]ally op]at$       
hospitals7 "u title ,,xviii ( ! ,social 
,security ,act 9 an am\nt equal to ! net
 am\nt ( additional co/s incurr$ 9      
provid+ s]vices to ,m$ic>e b5efici>ies t
 are attributable to compliance )       
requirem5ts impos$ "u sections #cdja    
?r\gh #cdjc4 ,! am\nt ( su* paym5t      
adju/m5ts %all take into acc\nt         
recomm5dations conta9$ 9 ! report       
submitt$ by ! ,m$ic>e ,paym5t ,advisory 
,commission "u subsection 7c74  7b7     
,au?orization ( appropriation = f$]ally 
op]at$ hospitals ,!re are au?oriz$ to be
 appropriat$ su* additional sums z are  
requir$ = f$]ally op]at$ hospitals to   
comply ) ! additional requirem5ts       
e/abli%$ "u sections #cdja ?r\gh #cdjc4 

7c7 ,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    
,pr(essional obligation & rights ,all   
nurses h a duty & "r to act bas$ on _!  
pr(essional judgm5t 9 accordance ) ,/ate
 nurs+ laws & regulations ( ! ,/ate 9   
:i* ! direct nurs+ c>e is be+ p]=m$ & to
 provide c>e 9 ! exclusive int]e/s ( !  
pati5ts & to act z ! pati5t's advocate4 
7b7 ,acceptance ( pati5t c>e assignm5ts 
,! nurse is responsible = provid+       
compet5t1 safe1 !rapeutic1 & effective  
nurs+ c>e to assign$ pati5ts4 ,be=e     
accept+ a pati5t assignm5t1 a nurse     

%all-- 7#a7 h ! necess>y pr(essional k1 
judgm5t1 skills1 & ability to provide ! 
requir$ c>e2  7#b7 det]m9e us+          
pr(essional judgm5t 9 accordance ) ,/ate
 nurs+ laws & regulations ( ! ,/ate 9   
:i* ! direct nurs+ c>e is be+ p]=m$ :e!r
 ! nurse is compet5t to p]=m ! nurs+ c>e
 requir$2 &  7#c7 det]m9e :e!r          
acceptance ( a pati5t assignm5t w\ld    
expose ! pati5t or nurse to risk ( h>m4 
7c7 ,objection to or refusal ( assignm5t
 ,a nurse may object to1 or refuse to   
p>ticipate 91 any activity1 policy1     
practice1 assignm5t1 or task if 9 good  
fai?-- 7#a7 ! nurse reasonably believes 
x to be 9 violation ( section #cdja or  
#cdjc2 or  7#b7 ! nurse is n prep>$ by  
education1 tra9+1 or exp]i5ce to fulfill
 ! assignm5t )\t compromis+ ! safety (  
any pati5t or jeop>diz+ ! lic5se ( !    
nurse4  7d7 ,retaliation = objection to 
or refusal ( assignm5t b>r$  7#a7 ,no   
dis*>ge1 discrim9ation1 or retaliation  
,no hospital %all dis*>ge1 retaliate1   
discrim9ate1 or o!rwise take adv]se     

action 9 any mann] ) respect to any     
aspect ( a nurse's employm5t 7z def9$ 9 
section #cdjg71 includ+ dis*>ge1        
promotion1 comp5sation1 or t]ms1        
conditions1 or privileges ( employm5t1  
bas$ on ! nurse's refusal ( a "w        
assignm5t "u subsection 7c74  7#b7 ,no  
fil+ ( compla9t ,no hospital %all file a
 compla9t or a report aga9/ a nurse ) a 
,/ate pr(essional discipl9>y ag5cy      
because ( ! nurse's refusal ( a "w      
assignm5t "u subsection 7c74  7e7 ,cause
 ( action ,any nurse1 collective b>ga9+ 
repres5tative1 or legal repres5tative ( 
any nurse :o has be5 dis*>g$1           
discrim9at$ aga9/1 or retaliat$ aga9/ 9 
violation ( subsection 7d77#a7 or aga9/ 
:om a compla9t or report has be5 fil$ 9 
violation ( subsection 7d77#b7 may 7)\t 
reg>d to :e!r a compla9t has be5 fil$ "u
 subsection 7f7 ( ?is section or        
subsection 7b7 ( section #cdjf7 br+ a   
cause ( action 9 a ,unit$ ,/ates di/rict
 c\rt4 ,a nurse :o prevails on ! cause (
 action %all be entitl$ to "o or m ( !  

foll[+3 7#a7 ,re9/atem5t4  7#b7         
,reimbursem5t ( lo/ wages1 comp5sation1 
& b5efits4  7#c7 ,attorneys' fees4  7#d7
 ,c\rt co/s4  7#e7 ,o!r damages4  7f7   
,compla9t to secret>y ,a nurse1 pati5t1 
collective b>ga9+ repres5tative1 or o!r 
individual may file a compla9t ) !      
,secret>y aga9/ a hospital t violates ! 
provisions ( ?is title4 ,= any compla9t 
fil$1 ! ,secret>y %all-- 7#a7 receive & 
inve/igate ! compla9t2  7#b7 det]m9e    
:e!r a violation ( ?is title z alleg$ 9 
! compla9t has occurr$2 &  7#c7 if su* a
 violation has occurr$1 issue an ord] t 
! compla9+ nurse or individual %all n   
suff] any dis*>ge1 retaliation1         
discrim9ation1 or o!r adv]se action     
prohibit$ by subsection 7d7 or          
subsection 7h74  7g7 ,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 ?r\gh #cdjc & to receive  
reports ( violations ( su* section4     

7#b7 ,notice to pati5ts ,a hospital %all
 provide ea* pati5t admitt$ to !        
hospital = inpati5t c>e ) ! hotl9e      
describ$ 9 p>agraph 7#a71 & %all give   
notice to ea* pati5t t su* hotl9e may be
 us$ to report inadequate /aff+ or c>e4 
7h7 ,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  7i7          
,prohibition on int]f]5ce ) rights  7#a7
 ,ex]cise ( rights ,x %all be unlawful =
 any hospital to-- 7,a7 int]f]e )1      
re/ra91 or d5y ! ex]cise1 or attempt to 
ex]cise1 by any p]son ( any "r provid$  
or protect$ "u ?is title2 or  7,b7 co]ce
 or intimidate any p]son reg>d+ !       
ex]cise or attempt to ex]cise su* "r4   
7#b7 ,opposition to unlawful policies or
 practices ,x %all be unlawful = any    
hospital to discrim9ate or retaliate    
aga9/ any p]son = oppos+ any hospital   
policy1 practice1 or actions :i* are    
alleg$ to violate1 brea*1 or fail to    
comply ) any provision ( ?is title4     
7#c7 ,prohibition on int]f]5ce )        
protect$ communications ,a hospital 7or 
an individual repres5t+ a hospital7 %all
 n make1 adopt1 or en=ce any rule1      
regulation1 policy1 or practice :i* 9   

any mann] directly or indirectly        
prohibits1 imp$es1 or disc\rages a      
direct c>e nurse f1 or intimidates1     
co]ces1 or induces a direct c>e nurse   
reg>d+1 engag+ 9 free spee* activities  
or disclos+ in=mation z provid$ "u ?is  
title4  7#d7 ,prohibition on int]f]5ce )
 collective action ,a hospital 7or an   
individual repres5t+ a hospital7 %all n 
9 any way int]f]e ) ! rights ( nurses to
 organize1 b>ga9 collectively1 & engage 
9 conc]t$ activity "u section #g ( !    
,national ,labor ,relations ,act 7#bi   
,u4,s4,c4 #aeg74  7j7 ,notice ,a        
hospital %all po/ 9 an appropriate      
location 9 ea* unit a conspicu\s notice 
9 a =m specifi$ by ! ,secret>y t-- 7#a7 
expla9s ! rights ( nurses1 pati5ts1 &   
o!r individuals "u ?is section2  7#b7   
includes a /atem5t t a nurse1 pati5t1 or
 o!r individual may file a compla9t ) ! 
,secret>y aga9/ a hospital t violates ! 
provisions ( ?is title2 &  7#c7 provides
 in/ructions on h[ to file su* a        
compla9t4  7k7 ,effective date  7#a7    

,refusal2 retaliation2 cause ( action   
7,a7 ,9 g5]al ,subsections 7c7 ?r\gh 7e7
 %all apply to objections & refusals    
occurr+ on or aft] ! effective date ( ! 
provision ( ?is title to :i* ! objection
 or refusal relates4  7,b7 ,exception   
,subsection 7c77#b7 %all n apply to     
objections or refusals 9 any hospital   
be=e ! requirem5ts ( section #cdja7;a7  
or #cdjc7;a71 z applicable1 apply to t  
hospital4  7#b7 ,protections = report+  
,subsection 7h77#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$+ on or aft] ! date ( enactm5t (  
?is title4  7#c7 ,notice ,subsection 7j7
 %all take effect #ah mon?s aft] ! date 
( enactm5t ( ?is title4  #cdjf4         
,en=cem5t  7a7 ,9 g5]al ,! ,secret>y    
%all en=ce ! requirem5ts & prohibitions 
( ?is title 9 accordance ) ?is section4 
7b7 ,proc$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   
title a civil money p5alty (-- 7i7 n m  
?an #be1jjj = ! fir/ kn[+ violation (   
?is title by su* hospital2 &  7ii7 n m  
?an #ej1jjj = any subsequ5t kn[+        
violation ( ?is title by su* hospital4  
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$ ?is title2 &     
7ii7 kn[+ly violates ?is title1  a civil
 money p5alty ( n m ?an #bj1jjj = ea*   
su* violation by ! individual4  7#b7    
,proc$ures ,! provisions ( section      
#aabh;,a ( ! ,social ,security ,act 7o!r
 ?an subsections 7a7 & 7b77 %all apply )
 respect to a civil money p5alty or     
proce$+ "u ?is subsection 9 ! same mann]
 z su* provisions apply ) respect to a  
civil money p5alty or proce$+ "u su*    
section #aabh;,a4  7e7 ,public notice ( 
violations  7#a7 ,int]net website ,!    
,secret>y %all publi% on ! int]net      
website ( ! ,dep>tm5t ( ,heal? & ,human 
,s]vices ! names ( hospitals on :i* a   
civil money p5alty has be5 impos$ "u ?is
 section1 ! violation = :i* su* p5alty 0
 impos$1 & su* additional in=mation z ! 
,secret>y det]m9es appropriate4  7#b7   
,*ange ( own]%ip ,) respect to a        
hospital t _h a *ange ( own]%ip1 z      
det]m9$ by ! ,secret>y1 p5alties impos$ 

on ! hospital :ile "u previ\s own]%ip   
%all no long] be publi%$ by ! ,secret>y 
pursuant to p>agraph 7#a7 aft] ! #a-ye> 
p]iod beg9n+ on ! date ( *ange (        
own]%ip4  7f7 ,use ( funds ,funds       
collect$ by ! ,secret>y pursuant to ?is 
section are au?oriz$ to be appropriat$  
to c>ry out ?is title4  #cdjg4          
,def9itions ,= purposes ( ?is title3    
7#a7 ,acuity level ,! t]m acuity level  
means ! det]m9ation1 us+ a hospital     
acuity measurem5t tool t has be5        
develop$ & e/abli%$ 9 coord9ation )     
direct c>e regi/]$ nurses & made        
transp>5t pursuant to section           
#cdja7;c77#d71 ( nurs+ c>e requirem5ts1 
bas$ on ! assign$ direct c>e regi/]$    
nurse's pr(essional judgm5t (-- 7,a7 !  
sev]ity & complexity ( an individual    
pati5t's illness or injury2  7,b7 ! ne$ 
= specializ$ equipm5t2 &  7,c7 !        
int5sity ( nurs+ int]v5tions requir$4   
7#b7 ,compet5ce ,! t]m compet5ce or     
compet5t means ! satisfactory           
application ( ! duties &                

responsibilities ( a regi/]$ nurse 9    
provid+ nurs+ c>e to specific pati5t    
populations & = acuity levels = ea*     
pati5t c>e unit or area pursuant to !   
,/ate nurs+ laws & regulations ( ! ,/ate
 9 :i* ! direct nurs+ c>e is be+ p]=m$4 
7#c7 ,direct c>e lic5s$ practical nurse 
,! t]m direct c>e lic5s$ practical nurse
 means an individual :o has be5 grant$ a
 lic5se by at lea/ "o ,/ate to practice 
z a lic5s$ practical nurse or a lic5s$  
vocational nurse & :o provides b$side   
c>e = "o or m pati5ts4  7#d7 ,direct c>e
 regi/]$ nurse ,! t]m direct c>e regi/]$
 nurse means an individual :o has be5   
grant$ a lic5se by at lea/ "o ,/ate to  
practice z a regi/]$ nurse & :o provides
 b$side c>e = "o or m pati5ts4  7#e7    
,employm5t ,! t]m employm5t includes !  
provision ( s]vices "u a contract or o!r
 arrangem5t4  7#f7 ,hospital ,! t]m     
hospital has ! mean+ giv5 t t]m 9       
section #ahfa7;e7 ( ! ,social ,security 
,act1 & includes a hospital t is op]at$ 
by ! ,dep>tm5t ( ,vet]ans ,affairs1 !   

,dep>tm5t ( ,def5se1 ! ,indian ,heal?   
,s]vices ,program1 or any o!r dep>tm5t  
or ag5cy ( ! ,unit$ ,/ates4  7#g7 ,nurse
 ,! t]m nurse means any direct c>e      
regi/]$ nurse or direct c>e lic5s$      
practice nurse 7z ! case may be71       
reg>dless ( :e!r or n ! nurse is an     
employee4  7#h7 ,nurs+ c>e plan ,! t]m  
nurs+ c>e plan means a plan develop$ by 
! assign$ direct c>e regi/]$ nurse 79   
accordance ) nurs+ law 9 ! ,/ate 9 :i* !
 nurs+ c>e is p]=m$7 t indicates ! nurs+
 c>e to be giv5 to individual pati5ts   
t-- 7,a7 consid]s ! acuity level ( !    
pati5t2  7,b7 is develop$ 9 coord9ation 
) ! pati5t1 ! pati5t's family1 or o!r   
repres5tatives :5 appropriate1 & /aff ( 
o!r discipl9es involv$ 9 ! c>e ( !      
pati5t2  7,c7 reflects all elem5ts ( !  
nurs+ process2 &  7,d7 recomm5ds ! numb]
 & skill mix ( additional lic5s$ &      
unlic5s$ direct c>e /aff ne$$ to fully  
implem5t ! nurs+ c>e plan4  7#i7        
,pr(essional judgm5t ,! t]m pr(essional 
judgm5t means1 9 accordance ) ,/ate     

nurs+ laws & regulations ( ! ,/ate 9 :i*
 ! direct nurs+ c>e is be+ p]=m$1 !     
direct c>e regi/]$ nurse's application (
 k1 exp]tise1 & exp]i5ce 9 conduct+ a   
compreh5sive nurs+ assessm5t ( ea*      
pati5t & 9 mak+ indep5d5t decisions ab\t
 pati5t c>e includ+ ! ne$ = additional  
/aff4  7#aj7 ,/aff+ plan ,! t]m /aff+   
plan means a /aff+ plan requir$ "u      
section #cdja4  7#aa7 ,/ate ( em]g5cy ,!
 t]m /ate ( em]g5cy-- 7,a7 means a /ate 
( em]g5cy t is an unpr$ictable or       
unavoidable occurr5ce at an uns*$ul$ or 
unpr$ictable int]val1 relat+ to heal?   
c>e deliv]y & requir+ imm$iate m$ical   
int]v5tions & c>e2 &  7,b7 does n       
include a /ate ( em]g5cy t results f a  
labor dispute 9 ! heal? c>e indu/ry or  
consi/5t und]/aff+4  #cdjh4 ,rule (     
con/ruction ,no?+ 9 ?is title %all be   
con/ru$ to au?orize disclosure ( private
 & confid5tial pati5t in=mation1 if su* 
disclosure is n au?oriz$ or requir$ by  
o!r applicable law4  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 9     
subp>agraph 7,x71 by /rik+ 1 & & ins]t+ 
a comma2  7#b7 9 subp>agraph 7,y71 by   
/rik+ ! p]iod at ! end & ins]t+ 1 &2 &  
7#c7 by ins]t+ aft] ! subp>agraph 7,y7 !
 foll[+ new subp>agraph3  7,z7 9 ! case 
( a hospital1 to comply ) ! provisions (
 title ,,xxxiv ( ! ,public ,heal?       
,s]vice ,act4  4  7b7 ,m$icaid program  
,section #aijb7;a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acif;a7a77 is     
am5d$-- 7#a7 by /rik+ & at ! end (      
p>agraph 7#he72  7#b7 by /rik+ ! p]iod  
at ! end ( p>agraph 7#hf7 & ins]t+ 2 &2 
&  7#c7 by ins]t+ aft] p>agraph 7#hf7 ! 
foll[+ new p>agraph3  7#hg7 provide t   
any hospital t receives a paym5t "u su* 
plan comply ) ! provisions ( title      
,,xxxiv ( ! ,public ,heal? ,s]vice ,act 
7relat+ to m9imum direct c>e regi/]$    
nurse /aff+ requirem5ts74  4  7c7 ,heal?
 b5efits program ( ! dep>tm5t ( vet]ans 
affairs ,section #haaj7;a7 ( title #ch1 

,unit$ ,/ates ,code1 is am5d$ by add+ at
 ! end ! foll[+ new p>agraphs3  7#g7 ,9 
! case ( a ,dep>tm5t m$ical facility t  
is a hospital1 ! hospital %all comply ) 
! provisions ( title ,,xxxiv ( ! ,public
 ,heal? ,s]vice ,act4  7#h7 ,no?+ ei!r 9
 *apt] #gd ( ?is title or 9 section     
#gajf ( title #e %all preclude en=cem5t 
( ! provisions ( title ,,xxxiv ( !      
,public ,heal? ,s]vice ,act ) respect to
 a ,dep>tm5t hospital ?r\gh grievance   
proc$ures negotiat$ 9 accordance ) *apt]
 #ga ( title #e4  4  7d7 ,heal? b5efits 
program ( ! dep>tm5t ( def5se  7#a7 ,9  
g5]al ,*apt] #ee ( title #aj1 ,unit$    
,/ates ,code1 is am5d$ by add+ at ! end 
! foll[+ new section3  #aaaj;c4 ,/aff+  
requirem5ts ,9 ! case ( a facility ( !  
uni=m$ s]vices t is a hospital1 !       
hospital %all comply ) ! provisions (   
title ,,xxxiv ( ! ,public ,heal? ,s]vice
 ,act4  4  7#b7 ,cl]ical am5dm5t ,!     
table ( sections at ! beg9n+ ( su* *apt]
 is am5d$ by ins]t+ aft] ! item relat+  
to section #aaaj;b ! foll[+ new item3   

#aaaj;c4 ,/aff+ requirem5ts4  4  7e7    
,indian heal? s]vices program ,title    
,,viii ( ! ,indian ,heal? ,c>e          
,improvem5t ,act 7#be ,u4,s4,c4 #afga et
 seq47 is am5d$ by add+ at ! end !      
foll[+ new section3  #hcc4 ,/aff+       
requirem5ts ,all hospitals ( ! ,s]vice  
%all comply ) ! provisions ( title      
,,xxxiv ( ! ,public ,heal? ,s]vice ,act 
7relat+ to m9imum direct c>e regi/]$    
nurse /aff+ requirem5ts74  4  7f7 ,f$]al
 labor-,managem5t relations  7#a7 ,9    
g5]al ,section #gajf ( title #e1 ,unit$ 
,/ates ,code1 is am5d$ by add+ at ! end 
! foll[+3  7c7 ,no?+ 9 ?is section %all 
preclude en=cem5t ( ! provisions ( title
 ,,xxxiv ( ! ,public ,heal? ,s]vice ,act
 ?r\gh grievance proc$ures negotiat$ 9  
accordance ) section #gaba4  4  7#b7    
,con=m+ am5dm5t ,section #gajf7;a7 (    
title #e1 ,unit$ ,/ates ,code1 is am5d$ 
by /rik+ ,subject to subsection 7b7 (   
?is title1 & ins]t+ ,subject to         
subsections 7b7 & 7c714  #d4 ,nurse     
work=ce initiative  7a7 ,s*ol>%ip &     

/ip5d program ,section #hdf7;d7 ( !     
,public ,heal? ,s]vice ,act 7#db        
,u4,s4,c4 #bign7d77 is am5d$-- 7#a7 9 ! 
subsection head+1 by ins]t+ & ,/ip5d    
aft] ,s*ol>%ip2 &  7#b7 9 p>agraph 7#a71
 by ins]t+ or /ip5ds aft] s*ol>%ips4    
7b7 ,nurse ret5tion grants ,section     
#hca7;c77#a7 ( ! ,public ,heal? ,s]vice 
,act 7#db ,u4,s4,c4 #bifp7c77#a77 is    
am5d$-- 7#a7 by /rik+ ,grants = ,c>e]   
,ladd] ,program4-- & ins]t+ ,grants =   
,nurse ,ret5tion4--2  7#b7 9 subp>agraph
 7,b71 by /rik+ 2 & & ins]t+ a          
semicolon2  7#c7 9 subp>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   
program = 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