114 S864 IS: National Nursing Shortage Reform and Patient Advocacy Act U.S. Senate 2015-03-25 text/xml EN Pursuant to Title 17 Section 105 of the United States Code, this file is not subject to copyright protection and is in the public domain.
II114th CONGRESS1st SessionS. 864IN THE SENATE OF THE UNITED STATESMarch 25, 2015Mrs. Boxer (for herself and Mr. Brown) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and PensionsA BILLTo amend the Public Health Service Act to establish direct care registered nurse-to-patient staffing ratio requirements in hospitals, and for other purposes.
1.
Short title
This Act may be cited as the National Nursing Shortage Reform and Patient Advocacy Act.
2.
Minimum direct care registered nurse staffing requirements
(a)
Minimum direct care registered nurse staffing requirements
The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by adding at the end the following new title: <enum>XXXIV</enum><header>Minimum direct care registered nurse staffing requirements</header> <section id="H18214705752F4F91BCA2B84F4991628E"><enum>3401.</enum><header>Minimum nurse staffing requirements</header> <subsection id="HDB8F9B1E7F1D4349B050B9327ED52EE0"><enum>(a)</enum><header>Staffing plan</header> <paragraph id="H5F7EDD9B6F434AE5BF5DB3B7BE001289"><enum>(1)</enum><header>In general</header><text>A hospital shall implement a staffing plan that—</text> <subparagraph id="H377C1A9BC90E4888B58786BFC800CD5D"><enum>(A)</enum><text>provides adequate, appropriate, and quality delivery of health care services and protects patient safety; and</text> </subparagraph><subparagraph id="HA755017A7DF0455BBE4128007E87D5B9"><enum>(B)</enum><text>is consistent with the requirements of this title.</text> </subparagraph></paragraph><paragraph id="H53D5346067B44B2CA35520FB508DC03B"><enum>(2)</enum><header>Effective dates</header> <subparagraph id="HC9CA1652321943A7A3F4B72B930051E0"><enum>(A)</enum><header>Implementation of staffing plan</header><text>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.</text> </subparagraph><subparagraph id="HA81D8A9E099441B880749F895FCA9118"><enum>(B)</enum><header>Application of minimum direct care registered nurse-to-patient ratios</header><text>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 <act-name parsable-cite="SSA">Social Security Act</act-name>), not later than 4 years after the date of enactment of this title.</text> </subparagraph></paragraph></subsection><subsection id="HBC263A2A812A4DC9AA4CB8F04F8E1CE8"><enum>(b)</enum><header>Minimum direct care registered nurse-to-Patient ratios</header> <paragraph id="H2FB4063071DD44B8BBCF00A542368250"><enum>(1)</enum><header>In general</header><text>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):</text> <subparagraph id="H0957BA767CA94636A510D974FC1833AE"><enum>(A)</enum><text>One patient in trauma emergency units.</text> </subparagraph><subparagraph id="id84A21B45C2494CECAE03CF6BB0DB452A"><enum>(B)</enum><text>One patient in operating room units, provided that a minimum of 1 additional person serves as a scrub assistant in such unit.</text> </subparagraph><subparagraph id="H87AF171874D24FF80033B697DA6523E6"><enum>(C)</enum><text>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.</text> </subparagraph><subparagraph id="H084B2BBB9D2C4CE7A36DF8133DA4C85B"><enum>(D)</enum><text>Three patients in emergency room units, stepdown units, pediatrics units, telemetry units, antepartum units, and combined labor, delivery, and postpartum units.</text> </subparagraph><subparagraph id="HD9E02E1C514A44269F94BC005B20B1FF"><enum>(E)</enum><text>Four patients in medical-surgical units, intermediate care nursery units, psychiatric units, and other specialty care units.</text> </subparagraph><subparagraph id="HF5C68FE5E38B4866B3F12744EA313D94"><enum>(F)</enum><text>Five patients in rehabilitation units, and skilled nursing units.</text> </subparagraph><subparagraph id="HC8FD0DD2D47040889FBB19BF37D634DA"><enum>(G)</enum><text>Six patients in well-baby nursery units and postpartum (3 couplets) units.</text> </subparagraph></paragraph><paragraph id="HDEE53A5D7DD24DEF9576DA4D5781CCF"><enum>(2)</enum><header>Units with different names</header><text>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.</text> </paragraph><paragraph id="id4AB455CDD4D94FBF972054DDEC6A394B"><enum>(3)</enum><header>Restrictions</header> <subparagraph id="id1956B33F60FE45C4A92E929722B63EF6"><enum>(A)</enum><header>Prohibition against averaging</header><text>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.</text> </subparagraph><subparagraph id="id5EE68AEF01304910B290C696522FD5A7"><enum>(B)</enum><header>Prohibition against imposition of mandatory overtime requirements</header><text>A hospital shall not impose mandatory overtime requirements to meet the hospital unit direct care registered nurse-to-patient ratios required under this subsection.</text> </subparagraph><subparagraph id="id8D11D0A956D549568CE8651EA1B4094D"><enum>(C)</enum><header>Relief during routine absences</header><text>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.</text> </subparagraph></paragraph><paragraph id="HB3CF1BD9D244493A8E16CA0080E411DD"><enum>(4)</enum><header>Adjustment of ratios</header> <subparagraph id="H1A763CF34C9D41958CC7D4E078E613D6"><enum>(A)</enum><header>In general</header><text>If necessary to protect patient safety, the Secretary may prescribe regulations that—</text> <clause id="H26A79A023CF2497DBA500098E0A263E9"><enum>(i)</enum><text>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</text> </clause><clause id="H60E0E9B0DFBA430B85B19EE38433F690"><enum>(ii)</enum><text>add minimum direct care registered nurse-to-patient ratios for units not referred to in paragraphs (1) and (2).</text> </clause></subparagraph><subparagraph id="H00FBE7A252BB4DD08E3896C8A8008F86"><enum>(B)</enum><header>Consultation</header><text>Such regulations shall be prescribed after consultation with affected hospitals and registered nurses.</text> </subparagraph></paragraph><paragraph id="H1523BC5F08684A2AA9D5FBB9D86B0525"><enum>(5)</enum><header>No preemption of certain State-imposed ratios</header><text>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.</text> </paragraph><paragraph id="HCADFBB916292453D00DD1881F5F25BE"><enum>(6)</enum><header>Exemption in emergencies</header> <subparagraph id="idEE2441AAE8EF492F81FA5A247618137C"><enum>(A)</enum><header>In general</header><text>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.</text> </subparagraph><subparagraph id="id5A05B93A659B4F74A7D8F1952B1778A8"><enum>(B)</enum><header>Guidance</header><text>The Secretary shall issue guidance to hospitals that describes situations that constitute a state of emergency for purposes of the exemption under this paragraph.</text> </subparagraph></paragraph></subsection><subsection id="H13CB67F10095468882F66675CE17826"><enum>(c)</enum><header>Development and reevaluation of staffing plan</header> <paragraph id="HEC447D2FE90445628CE7CD58DDAF00"><enum>(1)</enum><header>Considerations in development of plan</header><text>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:</text> <subparagraph id="HE5ED4F6D3BF74235BEF5191DA2D2FAC2"><enum>(A)</enum><text>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.</text> </subparagraph><subparagraph id="H1A48C605B1D94804B5AB555EB754F6D"><enum>(B)</enum><text>The anticipated admissions, discharges, and transfers of patients during each shift that impacts direct patient care.</text> </subparagraph><subparagraph id="H823415E491AF4A989281C97B842B2BAF"><enum>(C)</enum><text>Specialized experience required of direct care registered nurses on a particular unit.</text> </subparagraph><subparagraph id="H3FD90EF6FAEC426381AA22E57540955C"><enum>(D)</enum><text>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.</text> </subparagraph><subparagraph id="H444208C46828459C81DB22B749BAB705"><enum>(E)</enum><text>The level and quality of technology available that affects the delivery of direct patient care.</text> </subparagraph><subparagraph id="HC98253D13C2E424E8087DF2F21933B36"><enum>(F)</enum><text>The level of familiarity with hospital practices, policies, and procedures by temporary agency direct care registered nurses used during a shift.</text> </subparagraph><subparagraph id="H41F929568464491D001483086BD1604"><enum>(G)</enum><text>Obstacles to efficiency in the delivery of patient care presented by physical layout.</text> </subparagraph></paragraph><paragraph id="H4F521DC9031243B4A6CAC28C8238AA9D"><enum>(2)</enum><header>Documentation of staffing</header><text>A hospital shall specify the system used to document actual staffing in each unit for each shift.</text> </paragraph><paragraph id="H2E572DA1F33344B283003200C85B9267"><enum>(3)</enum><header>Annual reevaluation of plan and acuity system</header> <subparagraph id="H374D2307B0F94612B2008FF7EE1E7902"><enum>(A)</enum><header>In general</header><text>A hospital shall annually evaluate—</text> <clause id="H743D20FBF23B449495B43034CC44E000"><enum>(i)</enum><text>its staffing plan in each unit in relation to actual patient care requirements; and</text> </clause><clause id="H2194597C304A490E00F96F7CA65F2376"><enum>(ii)</enum><text>the accuracy of its acuity system.</text> </clause></subparagraph><subparagraph id="H7DF324DE7A454C33B1411DF65BD7AA85"><enum>(B)</enum><header>Update</header><text>A hospital shall update its staffing plan and acuity system to the extent appropriate based on such evaluation.</text> </subparagraph></paragraph><paragraph id="id4C71EE4C6764428FA552B4AFF9B9B58B"><enum>(4)</enum><header>Transparency</header> <subparagraph id="id9DA72FAE3F0F47148338B203689E156D"><enum>(A)</enum><header>In general</header><text>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.</text> </subparagraph><subparagraph id="id6A8DA1A7FB9142FC8622EE456A52D897"><enum>(B)</enum><header>Public availability</header><text>The Secretary shall establish procedures to provide that the documentation submitted under subsection (e) is available for public inspection in its entirety.</text> </subparagraph></paragraph><paragraph id="H901A570DBE264C9F945F623BCF2C923D"><enum>(5)</enum><header>Registered nurse participation</header><text>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.</text> </paragraph></subsection><subsection id="idD2FCDE9893FB449E8AA6D5BFD7E92F50"><enum>(d)</enum><header>Acuity tool</header> <paragraph id="id123EF8304C1A499DBD4B550133D8BD8C"><enum>(1)</enum><header>In general</header><text>Not later than 2 years after the date of enactment of the <short-title>National Nursing Shortage Reform and Patient Advocacy Act</short-title>, 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).</text> </paragraph><paragraph id="idE3F2B629ABF94A4A9623BE6C7DCF4373"><enum>(2)</enum><header>Implementation</header><text>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.</text> </paragraph></subsection><subsection id="id15CE8BFC71AF42C3BDFC91B199074208"><enum>(e)</enum><header>Submission of plan to Secretary</header><text>A hospital shall submit to the Secretary its staffing plan required under subsection (a)(1) and any annual updates under subsection (c)(3)(B).</text> </subsection></section><section id="H6BF366EA2144424B95B1E78B3FD5CF68"><enum>3402.</enum><header>Posting, records, and audits</header> <subsection id="H5B75A03E1FC44D5299F3065511010087"><enum>(a)</enum><header>Posting requirements</header><text>In each unit, a hospital shall post a uniform notice in a form specified by the Secretary in regulation that—</text> <paragraph id="H75A0F9A184BB4BB18B67BC3C9D783389"><enum>(1)</enum><text>explains requirements imposed under section 3401;</text> </paragraph><paragraph id="H6783410D9F6B4DE282B09200FBD82E39"><enum>(2)</enum><text>includes actual direct care registered nurse-to-patient ratios during each shift; and</text> </paragraph><paragraph id="H6D81C8B2D58C45B69EF48CF69279B300"><enum>(3)</enum><text>is visible, conspicuous, and accessible to staff, patients, and the public.</text> </paragraph></subsection><subsection id="H65D87976940F44E9ABCC16FF15C1A2B"><enum>(b)</enum><header>Records</header> <paragraph id="H15B5E0820F394A0C876CA1007084FCF1"><enum>(1)</enum><header>Maintenance of records</header><text>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—</text> <subparagraph id="HBD953AF5174D4EA1B04145EBBE8120E2"><enum>(A)</enum><text>the number of patients in each unit;</text> </subparagraph><subparagraph id="H49446DE55D2148D19719A7D1505D7B53"><enum>(B)</enum><text>the identity and duty hours of each direct care registered nurse assigned to each patient in each unit in each shift; and</text> </subparagraph><subparagraph id="HF883739500404B1B89B3032D8E7E20EA"><enum>(C)</enum><text>a copy of each notice posted under subsection (a).</text> </subparagraph></paragraph><paragraph id="HFCF72B42E4DB4E5DA0F5A222824B7C17"><enum>(2)</enum><header>Availability of records</header><text>Each hospital shall make its records maintained under paragraph (1) available to—</text> <subparagraph id="H3DC9131CFC96424DADEB376DEFCB0447"><enum>(A)</enum><text>the Secretary;</text> </subparagraph><subparagraph id="H04B4371331B44DBD8169981C67FA084C"><enum>(B)</enum><text>registered nurses and their collective bargaining representatives (if any); and</text> </subparagraph><subparagraph id="H192E84171C91406BBA1800CF532C1400"><enum>(C)</enum><text>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 <quote>Freedom of Information Act</quote>).</text> </subparagraph></paragraph></subsection><subsection id="H1BF498A509D04E7DBEECE13EDCE1914F"><enum>(c)</enum><header>Audits</header><text>The Secretary shall conduct periodic audits to ensure—</text> <paragraph id="H0A72C153E21147919D2834FCBBC4674B"><enum>(1)</enum><text>implementation of the staffing plan in accordance with this title; and</text> </paragraph><paragraph id="H28AA16B9017E4072BDAEA642C5480988"><enum>(2)</enum><text>accuracy in records maintained under this section.</text> </paragraph></subsection></section><section id="HA035B6D5AE574BFDBB0669709E33357F"><enum>3403.</enum><header>Minimum direct care licensed practical nurse staffing requirements</header> <subsection id="HE4377D33B8DC425687007E747CC067B"><enum>(a)</enum><header>Establishment</header><text>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).</text> </subsection><subsection id="H7A3D74F7A7CD4D3CBC7195E24BD8EB"><enum>(b)</enum><header>Study</header><text>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.</text> </subsection><subsection id="HC4256DAA9A5A4F45B746FCD376382B07"><enum>(c)</enum><header>Application of registered nurse provisions to licensed practical nurse staffing requirements</header><text>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.</text> </subsection><subsection id="H34C0CBED9E71481080A6BE1BE69EF4D7"><enum>(d)</enum><header>Effective date</header><text>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 <act-name parsable-cite="SSA">Social Security Act</act-name>), not later than 4 years after the date of enactment of this title.</text> </subsection></section><section id="idBC8F947663FC4211BD244E9C81E18D9B"><enum>3404.</enum><header>Adjustment in reimbursement</header> <subsection id="id2DCEB009A81F4C26A32950E30710A04E"><enum>(a)</enum><header>Medicare reimbursement</header><text>The Secretary shall adjust payments made to hospitals under title XVIII of the <act-name parsable-cite="SSA">Social Security Act</act-name> 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).</text> </subsection><subsection id="id870709278C0D4AEF9C94C3B20FB43756"><enum>(b)</enum><header>MedPAC report</header><text>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 <act-name parsable-cite="SSA">Social Security Act</act-name>) 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).</text> </subsection></section><section id="idD389DF7B04344872933C4919B6E27770"><enum>3405.</enum><header>Whistleblower and patient protections</header> <subsection id="H6AE9AAC9CA0744A0B0D8EE491F76FBC6"><enum>(a)</enum><header>Recognition of duty and right of nurses To advocate in the exclusive interest of the patient</header><text>A nurse shall have the right to act as the patient’s advocate, as circumstances require, by—</text> <paragraph id="idD93504408EED4C708EC595BDB097714E"><enum>(1)</enum><text>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</text> </paragraph><paragraph id="id317850585DD14A2097649500BFA66C3D"><enum>(2)</enum><text>giving the patient an opportunity to make informed decisions about health care before it is provided.</text> </paragraph></subsection><subsection id="id1BA58269E26D460B81E3DBE222C5A0DF"><enum>(b)</enum><header>Refusal of assignment</header><text>A nurse may refuse to accept an assignment as a nurse in a hospital if—</text> <paragraph id="H05921ADD40FD4025A4678E00F1E1C21D"><enum>(1)</enum><text>the assignment would violate section 3401 or 3403; or</text> </paragraph><paragraph id="H47BD01D609504CE393CF17403DB4075F"><enum>(2)</enum><text>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.</text> </paragraph></subsection><subsection id="H30307BA79DE442B3AC15D971A8A24D76"><enum>(c)</enum><header>Retaliation for refusal of assignment barred</header> <paragraph id="H74C583E3D8A6445B88E4B4EC8B5E82AE"><enum>(1)</enum><header>No discharge, discrimination, or retaliation</header><text>No hospital shall discharge, discriminate, or retaliate in any manner with respect to any aspect of employment (as defined in section 3407(4)), 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).</text> </paragraph><paragraph id="HC47AC80A583341B2A0E443329B7F9404"><enum>(2)</enum><header>No filing of complaint</header><text>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).</text> </paragraph></subsection><subsection id="HCC1897C9FC774196B354FA988E4D46BE"><enum>(d)</enum><header>Cause of action</header><text>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:</text> <paragraph id="H51125CFF28A940E499B17B2349B76506"><enum>(1)</enum><text>Reinstatement.</text> </paragraph><paragraph id="HB601089264D94457AC86B3DFD2387D9F"><enum>(2)</enum><text>Reimbursement of lost wages, compensation, and benefits.</text> </paragraph><paragraph id="H9FBEF88F8FBF45B280DE61602E163029"><enum>(3)</enum><text>Attorneys’ fees.</text> </paragraph><paragraph id="HD1940F4F417545E8BB9FFB4C8D42ABD6"><enum>(4)</enum><text>Court costs.</text> </paragraph><paragraph id="H3BD226724B51415D8600B1A2D932D74F"><enum>(5)</enum><text>Other damages.</text> </paragraph></subsection><subsection id="HB0BB284491494FE3009C41B3B5F002C"><enum>(e)</enum><header>Complaint to Secretary</header> <paragraph id="id56B8AB550F774057BF9E1DDF9861574A"><enum>(1)</enum><header>In general</header><text>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—</text> <subparagraph id="HC92A4F0089A54BD588B619C04CAFDDA6"><enum>(A)</enum><text>receive and investigate the complaint;</text> </subparagraph><subparagraph id="H46CEE34A6F4D40B99EDF1139E720C2D"><enum>(B)</enum><text>determine whether a violation of this title as alleged in the complaint has occurred; and</text> </subparagraph><subparagraph id="H5E9186A4780641668CC846508CD93536"><enum>(C)</enum><text>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).</text> </subparagraph></paragraph></subsection><subsection id="id3814181E0027437CACFEEC825C2F57AD"><enum>(f)</enum><header>Toll-Free telephone number</header> <paragraph id="idC4EDD038836F4A9AA93E61AE7D3A6807"><enum>(1)</enum><header>In general</header><text>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.</text> </paragraph><paragraph id="idF7EEE038FDCC45B1B89EDA67BFEBFFFF"><enum>(2)</enum><header>Notice to patients</header><text>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.</text> </paragraph></subsection><subsection id="H0CE286AE3B094E3A80E7A4608DBA65D8"><enum>(g)</enum><header>Protection for reporting</header> <paragraph commented="no" id="H222591F33A0543B7AC6255B7A2C8B147"><enum>(1)</enum><header>Prohibition on retaliation or discrimination</header><text>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.</text> </paragraph><paragraph id="HE0974129D8FA428881C1B96ECF101739"><enum>(2)</enum><header>Good faith defined</header><text>For purposes of this subsection, an individual shall be deemed to be acting in good faith if the individual reasonably believes—</text> <subparagraph id="H20448E0DE54F40AD852443006BC9FD17"><enum>(A)</enum><text>the information reported or disclosed is true; and</text> </subparagraph><subparagraph id="H227F23B1BB944A4FA7DDD36F61CDB00"><enum>(B)</enum><text>a violation of this title has occurred or may occur.</text> </subparagraph></paragraph></subsection><subsection id="H923F47951FF44B71B287CCA34062B379"><enum>(h)</enum><header>Prohibition on interference with rights</header> <paragraph id="id87D16EF7CC0A48F18BE6706EDEDFF5CB"><enum>(1)</enum><header>Exercise of rights</header><text>It shall be unlawful for any hospital to—</text> <subparagraph id="idA791E07C5240491DA97861A6B10A3F3F"><enum>(A)</enum><text>interfere with, restrain, or deny the exercise, or attempt to exercise, by any person of any right provided or protected under this title; or</text> </subparagraph><subparagraph id="idF9E8D337FE6F45B69C75253532861057"><enum>(B)</enum><text>coerce or intimidate any person regarding the exercise or attempt to exercise such right.</text> </subparagraph></paragraph><paragraph id="id18933BF6B81040209F3BD5EA47E15AB1"><enum>(2)</enum><header>Opposition to unlawful policies or practices</header><text>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.</text> </paragraph><paragraph id="idBD2E3E8B9B3F4C3E9D244AE62D8911DE"><enum>(3)</enum><header>Prohibition on interference with protected communications</header><text>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.</text> </paragraph><paragraph id="id9E8FF7EEFAB34E919D4A936CC33D738E"><enum>(4)</enum><header>Prohibition on interference with collective action</header><text>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 (<external-xref legal-doc="usc" parsable-cite="usc/29/157">29 U.S.C. 157</external-xref>).</text> </paragraph></subsection><subsection id="id34595BB3332E4BCA8FE9550AAE20D64D"><enum>(i)</enum><header>Notice</header><text>A hospital shall post in an appropriate location in each unit a conspicuous notice in a form specified by the Secretary that—</text> <paragraph id="H9275F5DCB8C646B7A51F5F98DFE46BC4"><enum>(1)</enum><text>explains the rights of nurses, patients, and other individuals under this section;</text> </paragraph><paragraph id="HAD1B9235B6DD48FF9F19743DCAC4EB3E"><enum>(2)</enum><text>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</text> </paragraph><paragraph id="H0329E37352384CE78D4577197600E34F"><enum>(3)</enum><text>provides instructions on how to file a complaint under paragraph (2).</text> </paragraph></subsection><subsection id="H0E1A93A3C01B483C806B4BF23C338621"><enum>(j)</enum><header>Effective dates</header> <paragraph id="HA99B9234541047AE8294B43F0033285B"><enum>(1)</enum><header>Refusal; retaliation; cause of action</header> <subparagraph id="HDBCB5F048EEE46A5B61FE7E329C300E"><enum>(A)</enum><header>In general</header><text>Subsections (b) through (d) shall apply to refusals occurring on or after the effective date of the provision to which the refusal relates.</text> </subparagraph><subparagraph id="H9D219ADA230848CB008125B77372292"><enum>(B)</enum><header>Exception</header><text>Subsection (b)(2) shall not apply to refusals in any hospital before the requirements of section 3401(a) apply to that hospital.</text> </subparagraph></paragraph><paragraph id="H8A23FD06129A43A28BEEEF0558C9D3"><enum>(2)</enum><header>Protections for reporting</header><text>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.</text> </paragraph><paragraph id="H10CB6F94D16642E9B7005D772DB07EB5"><enum>(3)</enum><header>Notice</header><text>Subsection (i) shall take effect 18 months after the date of enactment of this title.</text> </paragraph></subsection></section><section id="id5327E3B2DD554AC38AF6D7CE29CC74E0"><enum>3406.</enum><header>Enforcement</header> <subsection id="id7F35D8D656D6444C940B2E6196E28560"><enum>(a)</enum><header>In general</header><text>The Secretary shall enforce the requirements and prohibitions of this title in accordance with this section.</text> </subsection><subsection id="id262A4CFE76B34B0587577ACDE7E2FAEC"><enum>(b)</enum><header>Procedures for receiving and investigating complaints</header><text>The Secretary shall establish procedures under which—</text> <paragraph id="id8E92878FA1C344E6B80840FDFBCA655B"><enum>(1)</enum><text>any person may file a complaint alleging that a hospital has violated a requirement or a prohibition of this title; and</text> </paragraph><paragraph id="idC7EE800C364C48AD9DA2F14A6E715E88"><enum>(2)</enum><text>such complaints shall be investigated by the Secretary.</text> </paragraph></subsection><subsection id="idE508B23253924412929098A7D4A7B2F5"><enum>(c)</enum><header>Remedies</header><text>If the Secretary determines that a hospital has violated a requirement of this title, the Secretary—</text> <paragraph id="id0B9BC87260144418814FB3ED49E2152B"><enum>(1)</enum><text>shall require the facility to establish a corrective action plan to prevent the recurrence of such violation; and</text> </paragraph><paragraph id="idE7EF0BC7BE8B49D3B3E0307054E98EE7"><enum>(2)</enum><text>may impose civil money penalties, as described in subsection (d).</text> </paragraph></subsection><subsection id="id0BAFBA2435CC48F79869C50AAAF4860B"><enum>(d)</enum><header>Civil penalties</header> <paragraph id="id822CCB0E75854DA7A3C94986B9497BB9"><enum>(1)</enum><header>In general</header><text>In addition to any other penalties prescribed by law, the Secretary may impose civil penalties as follows:</text> <subparagraph id="idFCF4D4FFAC594ECB91DAD82BC099A1D7"><enum>(A)</enum><header>Hospital liability</header><text>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).</text> </subparagraph><subparagraph id="id7EE7DF1A131A44479DF6EB0895BE494F"><enum>(B)</enum><header>Individual liability</header><text>The Secretary may impose on an individual who—</text> <clause id="idB9F136D5E72F475C9C8A78C19E19D2C2"><enum>(i)</enum><text>is employed by a hospital found by the Secretary to have violated a requirement of this title; and</text> </clause><clause id="id5521D986D389477DAC6C20B340474923"><enum>(ii)</enum><text>willfully violates this title,</text> </clause><continuation-text continuation-text-level="subparagraph">a civil money penalty of not more than $20,000 for each such violation.</continuation-text></subparagraph></paragraph><paragraph id="idED47B2674075483EB8AF8D7589E3A78A"><enum>(2)</enum><header>Procedures</header><text>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.</text> </paragraph></subsection><subsection id="id206F78374E3C4EC996E6FB64EF9CAF90"><enum>(e)</enum><header>Public notice of violations</header> <paragraph id="id62DBDF20CA8C4B54A4FEB18C5C43DCF1"><enum>(1)</enum><header>Internet website</header><text>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.</text> </paragraph><paragraph id="idC7E82E90B63C41B4A102377F45B14747"><enum>(2)</enum><header>Change of ownership</header><text>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.</text> </paragraph></subsection><subsection id="id95A175E410A84C8C890F23F2905260E9"><enum>(f)</enum><header>Offset</header><text>Funds collected by the Secretary under this section shall be used to offset the costs of enforcing this title.</text> </subsection></section><section id="H6E100D99C4894EFEAEC53C9CBD9BEC22"><enum>3407.</enum><header>Definitions</header><text display-inline="no-display-inline">For purposes of this title:</text> <paragraph id="H4571E5687E114329A0101DB8CB3C6F45"><enum>(1)</enum><header>Acuity system</header><text>The term <term>acuity system</term> means an established measurement tool that—</text> <subparagraph id="H7B99C82426634724BED829240019D1E"><enum>(A)</enum><text>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;</text> </subparagraph><subparagraph id="HE539C36B0A4D457600A1561757937D85"><enum>(B)</enum><text>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;</text> </subparagraph><subparagraph id="HAE922E9C320A4EDD8934A3BE7AB711C"><enum>(C)</enum><text>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</text> </subparagraph><subparagraph id="H1E5F8987E590461C90BFFB3C00DE9CB5"><enum>(D)</enum><text>is stated in terms that can be readily used and understood by nurses.</text> </subparagraph></paragraph><paragraph id="HEC23EAC1B35A4888900868462DF87057"><enum>(2)</enum><header>Direct care licensed practical nurse</header><text>The term <term>direct care licensed practical nurse</term> 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.</text> </paragraph><paragraph id="HAF24D2B1EA2D473FB500E55700B9DDB4"><enum>(3)</enum><header>Direct care registered nurse</header><text>The term <term>direct care registered nurse</term> 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.</text> </paragraph><paragraph id="H41F19AD6ECD74968A49DF777D4FDFD3E"><enum>(4)</enum><header>Employment</header><text>The term <term>employment</term> includes the provision of services under a contract or other arrangement.</text> </paragraph><paragraph id="H51BA31CB0F4A4A128933E3E35204A9C2"><enum>(5)</enum><header>Hospital</header><text>The term <term>hospital</term> has the meaning given that term in section 1861(e) of the <act-name parsable-cite="SSA">Social Security Act</act-name> 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).</text> </paragraph><paragraph id="H17F5AF64125549DCB4B129024911D8EC"><enum>(6)</enum><header>Nurse</header><text>The term <term>nurse</term> 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.</text> </paragraph><paragraph id="H352E49C3D7DD4007BCD1C9F1931557EB"><enum>(7)</enum><header>Staffing plan</header><text>The term <term>staffing plan</term> means a staffing plan required under section 3401.</text> </paragraph><paragraph id="id4D4AAFEA5BC14B11814255D578263B6B"><enum>(8)</enum><header>State of emergency</header><text>The term <term>state of emergency</term> 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.</text> </paragraph></section><section id="id29D525D858444EC59EF912EB47AC844C"><enum>3408.</enum><header>Rule of construction</header><text display-inline="no-display-inline">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.</text></section>. (b)
Recommendations to Congress
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). (c)
Report by HRSA
(1)
In general
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. (2)
Updated report
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).
3.
Enforcement of requirements through Federal programs
(a)
Medicare program
Section 1866(a)(1) of the Social Security Act (42 U.S.C. 1395cc(a)(1)) is amended— (1)by striking and at the end of subparagraph (V); (2)in subparagraph (W), as added by section 3005(1)(C) of the Patient Protection and Affordable Care Act (Public Law 111–148)— (A)by moving such subparagraph 2 ems to the left; and (B)by striking the period at the end and inserting a comma; (3)by redesignating subparagraph (W), as added by section 6406(b)(3) of the Patient Protection and Affordable Care Act (Public Law 111–148), as subparagraph (X) and moving such subparagraph 2 ems to the left; (4)in subparagraph (X), as redesignated by paragraph (3), by striking the period at the end and inserting , and; and (5)by inserting after subparagraph (X), as so redesignated, the following: (Y)in the case of a hospital, to be subject to the provisions of title XXXIV of the Public Health Service Act.. (b)
Medicaid program
Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)) is amended— (1)in paragraph (80), by striking and at the end; (2)in paragraph (81), by striking the period at the end and inserting ; and; and (3)by inserting after paragraph (81) the following new paragraph: (82)provide that any hospital receiving payments under such plan shall be subject to the provisions of title XXXIV of the Public Health Service Act.. (c)
Health Benefits Program of the Department of Veterans Affairs
Section 8110(a) of title 38, United States Code, is amended by adding at the end the following: (7)Subject to appropriations, the Secretary may require that a Department medical facility that is a hospital shall comply with the provisions of title XXXIV of the Public Health Service Act. (8)Nothing either in chapter 74 of this title or in section 7106 of title 5 shall preclude enforcement of the provisions of title XXXIV of the Public Health Service Act with respect to a Department medical facility that is a hospital through grievance procedures negotiated in accordance with chapter 71 of title 5.. (d)
Authorization of appropriations
There are authorized to be appropriated to the Secretary of Veterans Affairs, for compliance with title XXXIV of the Public Health Service Act pursuant to section 8110(a)(7) of title 38, United States Code, such sums as may be necessary for fiscal year 2016 and each subsequent fiscal year.
4.
Nurse Workforce Initiative
(a)
Scholarship and stipend program
Section 846(d) of the Public Health Service Act (42 U.S.C. 297n(d)) is amended— (1)in the section heading, by inserting and Stipend after Scholarship; and (2)in paragraph (1), by inserting or stipends after scholarships. (b)
Nurse retention grants
Section 831A(b) of the Public Health Service Act (42 U.S.C. 296p–1(b)) is amended— (1)by striking Grants for Career Ladder Program.— and inserting Grants for Nurse Retention.—; (2)in paragraph (2), by striking ; or and inserting a semicolon; (3)in paragraph (3), by striking the period and inserting a semicolon; and (4)by adding at the end the following: (4)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 students, newly hired nurses, and recent graduates of a direct care degree programs for registered nurses; or (5)to implement mentorship projects that assist new or transitional direct care registered nurses in adapting to the hospital setting..