Sec. 2. Minimum direct care registered nurse staffing requirements
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The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by adding at the end the following new title: A hospital shall implement a staffing plan that— provides adequate, appropriate, and quality delivery of health care services and protects patient safety; and is consistent with the requirements of this title. Subject to subparagraph (B), the requirements under paragraph
(1)shall take effect not later than 1 year after the date of enactment of this title. The requirements under subsection
(b)shall take effect as soon as practicable, as determined by the Secretary, but not later than 2 years after the date of enactment of this title, or in the case of a hospital in a rural area (as defined in section 1886(d)(2)(D) of the Social Security Act ), not later than 4 years after the date of enactment of this title. Except as otherwise provided in this section, a hospital’s staffing plan shall provide that, at all times during each shift within a unit of the hospital, a direct care registered nurse shall be assigned to not more than the following number of patients in that unit, subject to paragraph (4): One patient in trauma emergency units. One patient in operating room units, provided that a minimum of 1 additional person serves as a scrub assistant in such unit. Two patients in critical care units, including neonatal intensive care units, emergency critical care and intensive care units, labor and delivery units, coronary care units, acute respiratory care units, postanesthesia units, and burn units. Three patients in emergency room units, stepdown units, pediatrics units, telemetry units, antepartum units, and combined labor, delivery, and postpartum units. Four patients in medical-surgical units, intermediate care nursery units, psychiatric units, and other specialty care units. Five patients in rehabilitation units, and skilled nursing units. Six patients in well-baby nursery units and postpartum (3 couplets) units. The Secretary may apply minimum direct care registered nurse-to-patient ratios established in paragraph
(1)to a type of hospital unit not referred to in such paragraph if such other unit provides a level of care to patients whose needs are similar to the needs of patients cared for in any unit referred to in such paragraph. 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 1 shift or over any period of time for purposes of meeting the requirements under this subsection. A hospital shall not impose mandatory overtime requirements to meet the hospital unit direct care registered nurse-to-patient ratios required under this subsection. A hospital shall ensure that only a direct care registered nurse may relieve another direct care registered nurse during breaks, meals, and other routine, expected absences from a hospital unit. If necessary to protect patient safety, the Secretary may prescribe regulations that— increase minimum direct care registered nurse-to-patient ratios under this subsection to further limit the number of patients that may be assigned to each direct care nurse; or add minimum direct care registered nurse-to-patient ratios for units not referred to in paragraphs
(1)and (2). Such regulations shall be prescribed after consultation with affected hospitals and registered nurses. Nothing in this title shall preempt State standards that the Secretary determines to be at least equivalent to Federal requirements for a staffing plan established under this title. Minimum direct care registered nurse-to-patient ratios established under this subsection shall not preempt State requirements that the Secretary determines are at least equivalent to Federal requirements for a staffing plan established under this title. 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 services. The Secretary shall issue guidance to hospitals that describes situations that constitute a state of emergency for purposes of the exemption under this paragraph. In developing the staffing plan, 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
(b)if appropriate based upon consideration of the following factors: The number of patients and acuity level of patients as determined by the application of an acuity system (as defined in section 3407(1)), on a shift-by-shift basis. The anticipated admissions, discharges, and transfers of patients during each shift that impacts direct patient care. Specialized experience required of direct care registered nurses on a particular unit. Staffing levels and services provided by licensed vocational or practical nurses, licensed psychiatric technicians, certified nurse assistants, or other ancillary staff in meeting direct patient care needs not required by a direct care registered nurse. The level and quality of technology available that affects the delivery of direct patient care. The level of familiarity with hospital practices, policies, and procedures by temporary agency direct care registered nurses used during a shift. Obstacles to efficiency in the delivery of patient care presented by physical layout. A hospital shall specify the system used to document actual staffing in each unit for each shift. A hospital shall annually evaluate— its staffing plan in each unit in relation to actual patient care requirements; and the accuracy of its acuity system. A hospital shall update its staffing plan and acuity system to the extent appropriate based on such evaluation. Any acuity-based patient classification system adopted by a hospital under this section shall be transparent in all respects, including disclosure of detailed documentation of the methodology used to predict nursing staffing, identifying each factor, assumption, and value used in applying such methodology. The Secretary shall establish procedures to provide that the documentation submitted under subsection
(e)is available for public inspection in its entirety. A staffing plan of a hospital shall be developed and subsequent reevaluations shall be conducted under this subsection on the basis of input from direct care registered nurses at the hospital or, where such nurses are represented through collective bargaining, from the applicable recognized or certified collective bargaining representative of such nurses. Nothing in this title shall be construed to permit conduct prohibited under the National Labor Relations Act or under the Federal Labor Relations Act. Not later than 2 years after the date of enactment of the National Nursing Shortage Reform and Patient Advocacy Act , the Secretary shall develop a national acuity tool that provides a transparent method for establishing nurse staffing requirements above the hospital unit direct care registered nurse-to-patient ratios required under subsection (b). Each hospital may adopt and implement the national acuity tool described in paragraph (1), and provide staffing based on such tool. Any additional direct care registered nursing staffing above the hospital unit direct care registered nurse-to-patient ratios described in subsection
(b)shall be assigned in a manner determined by such national acuity tool. A hospital shall submit to the Secretary its staffing plan required under subsection (a)(1) and any annual updates under subsection (c)(3)(B). In each unit, a hospital shall post a uniform notice in a form specified by the Secretary in regulation that— explains requirements imposed under section 3401; includes actual direct care registered nurse-to-patient ratios during each shift; and is visible, conspicuous, and accessible to staff, patients, and the public. 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 2 years. Such records shall include— the number of patients in each unit; the identity and duty hours of each direct care registered nurse assigned to each patient in each unit in each shift; and a copy of each notice posted under subsection (a). Each hospital shall make its records maintained under paragraph
(1)available to— the Secretary; registered nurses and their collective bargaining representatives (if any); and the public under regulations established by the Secretary, or in the case of a federally operated hospital, under section 552 of title 5, United States Code (commonly known as the Freedom of Information Act ). The Secretary shall conduct periodic audits to ensure— implementation of the staffing plan in accordance with this title; and accuracy in records maintained under this section. A hospital’s staffing plan shall comply with minimum direct care licensed practical nurse staffing requirements that the Secretary establishes for units in hospitals. Such staffing requirements shall be established not later than 18 months after the date of enactment of this title, and shall be based on the study conducted under subsection (b). Not later than 1 year after the date of enactment of this title, the Secretary, acting through the Director of the Agency for Healthcare Research and Quality, shall complete a study of licensed practical nurse staffing and its effects on patient care in hospitals. The Director may contract with a qualified entity or organization to carry out such study under this paragraph. The Director shall consult with licensed practical nurses and organizations representing licensed practical nurses regarding the design and conduct of the study. Paragraphs (2), (4), (5)(A), and
(6)of section 3401(b), section 3401(c), and section 3402 shall apply to the establishment and application of direct care licensed practical nurse staffing requirements under this section in the same manner that they apply to the establishment and application of direct care registered nurse-to-patient ratios under sections 3401 and 3402. The requirements of this section shall take effect as soon as practicable, as determined by the Secretary, but not later than 2 years after the date of enactment of this title, or in the case of a hospital in a rural area (as defined in section 1886(d)(2)(D) of the Social Security Act ), not later than 4 years after the date of enactment of this title. The Secretary shall adjust payments made to hospitals under title XVIII of the Social Security Act in an amount equal to the net amount of additional costs incurred in providing services to Medicare beneficiaries that are attributable to compliance with requirements imposed under sections 3401 through 3403. The amount of such payment adjustments shall take into account recommendations contained in the report submitted by the Medicare Payment Advisory Commission under subsection (b). Not later than 2 years after the date of the enactment of this title, the Medicare Payment Advisory Commission (established under section 1805 of the Social Security Act ) shall submit to Congress and the Secretary a report estimating total costs and savings attributable to compliance with requirements imposed under sections 3401 through 3403. Such report shall include recommendations on the need, if any, to adjust reimbursement for Medicare payments under subsection (a). A nurse shall have the right to act as the patient’s advocate, as circumstances require, by— initiating action to improve health care or to change decisions or activities, including the recommendations of health information technology tools, which, in the professional judgment of the nurse, are against the interests and wishes of the patient; and giving the patient an opportunity to make informed decisions about health care before it is provided. A nurse may refuse to accept an assignment as a nurse in a hospital if— the assignment would violate section 3401 or 3403; or the nurse is not prepared by education, training, or experience to fulfill the assignment without compromising the safety of any patient or jeopardizing the license of the nurse. No hospital shall discharge, discriminate, or retaliate in any manner with respect to any aspect of employment (as defined in section 3407(5)), including discharge, promotion, compensation, or terms, conditions, or privileges of employment against a nurse based on the nurse’s refusal of a work assignment under subsection (b). No hospital shall file a complaint or a report against a nurse with the appropriate State professional disciplinary agency because of the nurse’s refusal of a work assignment described in subsection (b). Any nurse who has been discharged, discriminated against, or retaliated against in violation of subsection (c)(1) or against whom a complaint has been filed in violation of subsection (c)(2) may bring a cause of action in a United States district court. A nurse who prevails on the cause of action shall be entitled to one or more of the following: Reinstatement. Reimbursement of lost wages, compensation, and benefits. Attorneys’ fees. Court costs. Other damages. A nurse, patient, or other individual may file a complaint with the Secretary against a hospital that violates the provisions of this title. For any complaint filed, the Secretary shall— receive and investigate the complaint; determine whether a violation of this title as alleged in the complaint has occurred; and if such a violation has occurred, issue an order that the complaining nurse or individual shall not suffer any retaliation described in subsection
(c)or subsection (g). The Secretary shall provide for the establishment of a toll-free telephone hotline to provide information regarding the requirements under section 3401 and to receive reports of violations of such section. A hospital shall provide each patient admitted to the hospital for inpatient care with the hotline described in paragraph (1), and shall give notice to each patient that such hotline may be used to report inadequate staffing or care. A hospital shall not discriminate or retaliate in any manner against any patient, employee, or contract employee of the hospital, or any other individual, on the basis that such individual, in good faith, individually or in conjunction with another person or persons, has presented a grievance or complaint, or has initiated or cooperated in any investigation or proceeding of any governmental entity, regulatory agency, or private accreditation body, made a civil claim or demand, or filed an action relating to the care, services, or conditions of the hospital or of any affiliated or related facilities. For purposes of this subsection, an individual shall be deemed to be acting in good faith if the individual reasonably believes— the information reported or disclosed is true; and a violation of this title has occurred or may occur. It shall be unlawful for any hospital to— interfere with, restrain, or deny the exercise, or attempt to exercise, by any person of any right provided or protected under this title; or coerce or intimidate any person regarding the exercise or attempt to exercise such right. It shall be unlawful for any hospital to discriminate or retaliate against any person for opposing any hospital policy, practice, or actions which are alleged to violate, breach, or fail to comply with any provision of this title. A hospital (or an individual representing a hospital) shall not make, adopt, or enforce any rule, regulation, policy, or practice which in any manner directly or indirectly prohibits, impedes, or discourages a direct care registered nurse from, or intimidates, coerces, or induces a direct care registered nurse regarding, engaging in free speech activities or disclosing information as provided under this title. A hospital (or an individual representing a hospital) shall not in any way interfere with the rights of nurses to organize, bargain collectively, and engage in concerted activity under section 7 of the National Labor Relations Act ( 29 U.S.C. 157 ). A hospital shall post in an appropriate location in each unit a conspicuous notice in a form specified by the Secretary that— explains the rights of nurses, patients, and other individuals under this section; includes a statement that a nurse, patient, or other individual may file a complaint with the Secretary against a hospital that violates the provisions of this title; and provides instructions on how to file a complaint under paragraph (2). Subsections
(b)through
(d)shall apply to refusals occurring on or after the effective date of the provision to which the refusal relates. Subsection (b)(2) shall not apply to refusals in any hospital before the requirements of section 3401(a) apply to that hospital. Subsection (g)(1) shall apply to actions occurring on or after the effective date of the provision to which the violation relates, except that such subsection shall apply to initiation, cooperation, or participation in an investigation or proceeding on or after the date of enactment of this title. Subsection
(i)shall take effect 18 months after the date of enactment of this title. The Secretary shall enforce the requirements and prohibitions of this title in accordance with this section. The Secretary shall establish procedures under which— any person may file a complaint alleging that a hospital has violated a requirement or a prohibition of this title; and such complaints shall be investigated by the Secretary. If the Secretary determines that a hospital has violated a requirement of this title, the Secretary— shall require the facility to establish a corrective action plan to prevent the recurrence of such violation; and may impose civil money penalties, as described in subsection (d). In addition to any other penalties prescribed by law, the Secretary may impose civil penalties as follows: The Secretary may impose on a hospital found to be in violation of this title, a civil money penalty of not more than $25,000 for each knowing violation of a requirement of this title, except that the Secretary shall impose a civil money penalty of more than $25,000 for each such violation in the case of a participating hospital that the Secretary determines has a pattern or practice of such violations (with the amount of such additional penalties being determined in accordance with a schedule or methodology specified in regulations). The Secretary may impose on an individual who— is employed by a hospital found by the Secretary to have violated a requirement of this title; and willfully violates this title, a civil money penalty of not more than $20,000 for each such violation. The provisions of section 1128A of the Social Security Act (other than subsections
(a)and (b)) shall apply to a civil money penalty under this paragraph in the same manner as such provisions apply to a penalty or proceeding under such section 1128A. The Secretary shall publish on the Internet website of the Department of Health and Human Services the names of participating hospitals on which civil money penalties have been imposed under this subsection, the violation for which such penalty was imposed, and such additional information as the Secretary determines appropriate. With respect to a participating hospital that had a change in ownership, as determined by the Secretary, penalties imposed on the hospital while under previous ownership shall no longer be published by the Secretary of such Internet website after the 1-year period beginning on the date of change in ownership. Funds collected by the Secretary under this section shall be used to offset the costs of enforcing this title. For purposes of this title: The term acuity system means an established measurement tool that— predicts nursing care requirements for individual patients based on severity of patient illness, need for specialized equipment and technology, intensity of nursing interventions required, and the complexity of clinical nursing judgment needed to design, implement, and evaluate the patient’s nursing care plan; details the amount of nursing care needed, both in number of nurses and in skill mix of nursing personnel required, on a daily basis, for each patient in a nursing department or unit; takes into consideration the patient care services provided not only by registered nurses but also by direct care licensed practical nurses and other health care personnel; and is stated in terms that can be readily used and understood by nurses. The term direct care licensed practical nurse means an individual who has been granted a license by at least 1 State to practice as a licensed practical nurse or a licensed vocational nurse and who provides bedside care for 1 or more patients. The term direct care registered nurse means an individual who has been granted a license by at least 1 State to practice as a registered nurse and who provides bedside care for 1 or more patients. The term employment includes the provision of services under a contract or other arrangement. The term hospital has the meaning given that term in section 1861(e) of the Social Security Act and includes a hospital that is operated by the Department of Veterans Affairs and a long-term care hospital (as defined in section 1861(ccc) of such Act). The term nurse means any direct care registered nurse or direct care licensed practical nurse (as the case may be), regardless of whether or not the nurse is an employee. The term staffing plan means a staffing plan required under section 3401. The term state of emergency means a state of emergency that is an unpredictable or unavoidable occurrence at an unscheduled or unpredictable interval, relating to health care delivery and requiring immediate medical interventions and care, but such term does not include a state of emergency that results from a labor dispute in the health care industry or consistent understaffing. Nothing in this title shall be construed to authorize disclosure of private and confidential patient information, except in the case where such disclosure is otherwise required by law, compelled by proper legal process, consented to by the patient, provided in confidence to regulatory or accreditation agencies or other government entities for investigatory purposes, or provided pursuant to formal or informal complaints of unlawful or improper practices for purposes of achieving corrective and remedial action. . Not later than 1 year after the date of enactment of this Act, 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 Act , as added by subsection (a). Not later than 2 years after the date of enactment of this Act, the Administrator of the Health Resources and Services Administration, in consultation with the National Health Care Workforce Commission, shall submit to Congress a report regarding the relationship between nurse staffing levels and nurse retention in hospitals. Not later than 5 years after the date of enactment of this Act, the Administrator of the Health Resources and Services Administration, in consultation with the National Health Care Workforce Commission, shall submit to Congress an update of the report submitted under paragraph (1).
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