[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3415 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 3415
To amend the Public Health Service Act to establish direct care
registered nurse-to-patient staffing ratio requirements in hospitals,
and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
May 14, 2025
Ms. Schakowsky (for herself, Mr. Doggett, Mr. Cohen, Ms. Norton, Mr.
Casar, Ms. Brownley, Ms. Kelly of Illinois, Mr. Quigley, Mr. Khanna,
Ms. Bonamici, Mr. Huffman, Ms. Ocasio-Cortez, Mr. Krishnamoorthi, Mrs.
McIver, Ms. Jayapal, Ms. Chu, Ms. Tlaib, and Ms. Titus) introduced the
following bill; which was referred to the Committee on Energy and
Commerce, and in addition to the Committee on Ways and Means, for a
period to be subsequently determined by the Speaker, in each case for
consideration of such provisions as fall within the jurisdiction of the
committee concerned
_______________________________________________________________________
A BILL
To amend the Public Health Service Act to establish direct care
registered nurse-to-patient staffing ratio requirements in hospitals,
and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS; FINDINGS.
(a) Short Title.--This Act may be cited as the ``Nurse Staffing
Standards for Hospital Patient Safety and Quality Care Act of 2025''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents; findings.
Sec. 2. Minimum direct care registered nurse staffing requirement.
Sec. 3. Enforcement of requirements through Federal programs.
Sec. 4. Nurse workforce initiative.
(c) Findings.--Congress finds the following:
(1) The Federal Government has a substantial interest in
promoting quality care and improving the delivery of health
care services to patients in health care facilities in the
United States.
(2) Recent changes in health care delivery systems that
have resulted in higher acuity levels among patients in health
care facilities increase the need for improved quality measures
in order to protect patient care and reduce the incidence of
medical errors.
(3) Inadequate and poorly monitored registered nurse
staffing practices that result in too few registered nurses
providing direct care jeopardize the delivery of quality health
care services.
(4) Numerous studies have shown that patient outcomes are
directly correlated to direct care registered nurse staffing
levels, including a 2010 Health Services Research study that
concluded that implementation of minimum nurse-to-patient
staffing ratios in California has led to improved patient
outcomes and nurse retention and a 2014 Agency for Healthcare
Research and Quality study that concluded increases in nurse
staffing and skill mix lead to improved quality and reduced
length of stay at no additional cost.
(5) Requirements for direct care registered nurse staffing
ratios will help address the registered nurse shortage in the
United States by aiding in recruitment of new registered nurses
and improving retention of registered nurses who are
considering leaving direct patient care because of demands
created by inadequate staffing.
(6) Establishing adequate minimum direct care registered
nurse-to-patient ratios that take into account patient acuity
measures will improve the delivery of quality health care
services and guarantee patient safety.
(7) Establishing safe staffing standards for direct care
registered nurses is a critical component of assuring that
there is adequate hospital staffing at all levels to improve
the delivery of quality care and protect patient safety.
SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE STAFFING REQUIREMENT.
(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:
``TITLE XXXIV--MINIMUM DIRECT CARE REGISTERED NURSE STAFFING
REQUIREMENT
``SEC. 3401. MINIMUM NURSE STAFFING REQUIREMENT.
``(a) Staffing Plan.--
``(1) In general.--A hospital shall implement a staffing
plan that--
``(A) provides adequate, appropriate, and quality
delivery of health care services and protects patient
safety; and
``(B) is consistent with the requirements of this
title.
``(2) Effective dates.--
``(A) Implementation of staffing plan.--Subject to
subparagraph (B), the requirements under paragraph (1)
shall take effect on a date to be determined by the
Secretary, but not later than 1 year after the date of
the enactment of this title.
``(B) Application of minimum direct care registered
nurse-to-patient ratios.--The requirements under
subsection (b) shall take effect as soon as
practicable, as determined by the Secretary, but not
later than--
``(i) 2 years after the date of enactment
of this title; and
``(ii) in the case of a hospital in a rural
area (as defined in section 1886(d)(2)(D) of
the Social Security Act), 4 years after the
date of enactment of this title.
``(b) Minimum Direct Care Registered Nurse-to-Patient Ratios.--
``(1) In general.--Except as provided in paragraph (4) and
other provisions of this section, a hospital's staffing plan
shall provide that, at all times during each shift within a
unit of the hospital, and with a full complement of ancillary
and support staff, a direct care registered nurse may be
assigned to not more than the following number of patients in
that unit:
``(A) One patient in trauma emergency units.
``(B) One patient in operating room units, provided
that a minimum of 1 additional person serves as a scrub
assistant in such unit.
``(C) 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.
``(D) Three patients in emergency room units,
pediatrics units, stepdown units, telemetry units,
antepartum units, and combined labor, deliver, and
postpartum units.
``(E) Four patients in medical-surgical units,
intermediate care nursery units, acute care psychiatric
units, and other specialty care units.
``(F) Five patients in rehabilitation units and
skilled nursing units.
``(G) Six patients in postpartum (3 couplets) units
and well-baby nursery units.
``(2) Similar units with different names.--The Secretary
may apply minimum direct care registered nurse-to-patient
ratios established in paragraph (1) for a hospital unit
referred to in such paragraph to a type of hospital unit not
referred to in such paragraph if such type of hospital unit
provides a level of care to patients whose needs are similar to
the needs of patients cared for in the hospital unit referred
to in such paragraph.
``(3) Application of ratios to hospital nursing practice
standards.--
``(A) In general.--A patient assignment may be
included in the calculation of the direct care
registered nurse-to-patient ratios required in this
subsection only if care is provided by a direct care
registered nurse and the provision of care to the
particular patient is within that direct care
registered nurse's competence.
``(B) Demonstration of unit-specific competence.--A
hospital shall not assign a direct care registered
nurse to a hospital unit unless that hospital
determines that the direct care registered nurse has
demonstrated current competence in providing care in
that unit, and has also received orientation to that
hospital's unit sufficient to provide competent care to
patients in that unit.
``(C) Duties of the assigned direct care registered
nurse.--Each patient shall be assigned to a direct care
registered nurse who shall directly provide the
assessment, planning, supervision, implementation, and
evaluation of the nursing care provided to the patient
at least every shift and has the responsibility for the
provision of care to a particular patient within his or
her scope of practice.
``(D) Nurse administrators and supervisors.--A
registered nurse who is a nurse administrator, nurse
supervisor, nurse manager, charge nurse, case manager,
or any other hospital administrator or supervisor,
shall not be included in the calculation of the direct
care registered nurse-to-patient ratio unless that
nurse has a current and active direct patient care
assignment and provides direct patient care in
compliance with the requirements of this section,
including competency requirements. The exemption in
this subsection shall apply only during the hours in
which the individual registered nurse has the principal
responsibility of providing direct patient care and has
no additional job duties as would a direct care
registered nurse.
``(E) Other personnel.--Other personnel may perform
patient care tasks based on their training and
demonstrated skill but may not perform or assist in
direct care registered nurse functions unless
authorized to do in accordance with State scope of
practice laws and regulations.
``(F) Temporary nursing personnel.--A hospital
shall not assign any nursing personnel from temporary
nursing agencies patient care to any hospital unit
without such personnel having demonstrated competence
on the assigned unit and received orientation to that
hospital's unit sufficient to provide competent care to
patients in that unit.
``(G) Ancillary and additional staffing.--The need
for additional staffing of direct care registered
nurses, licensed vocational or practical nurses,
licensed psychiatric technicians, certified nursing or
patient care assistants, or other licensed or
unlicensed ancillary staff above the minimum registered
nurse-to-patient ratios shall be based on the
assessment of the individual patient's nursing care
requirement, the individual patient's nursing care
plan, and acuity level.
``(4) Restrictions.--
``(A) Prohibition against averaging.--A hospital
shall not average the number of patients and the total
number of direct care registered nurses assigned to
patients in a hospital unit during any 1 shift or over
any period of time for purposes of meeting the
requirements under this subsection.
``(B) Prohibition against imposition of mandatory
overtime requirements.--A hospital shall not impose
mandatory overtime requirements to meet the hospital
unit direct care registered nurse-to-patient ratios
required under this subsection.
``(C) Relief during routine absences.--A hospital
shall ensure that only a direct care registered nurse
who has demonstrated current competence to the hospital
in providing care on a particular unit and has also
received orientation to that hospital's unit sufficient
to provide competent care to patients in that unit may
relieve another direct care registered nurse during
breaks, meals, and other routine, expected absences
from a hospital unit.
``(D) Application of direct care registered nurse-
to-patient ratios in patient-acuity adjustable units.--
Patients shall be cared for only on units or patient
care areas where the direct care registered nurse-to-
patient ratios meet the level of intensity, type of
care, and the individual requirements and needs of each
patient. Notwithstanding paragraph (2), hospitals that
provide patient care in units or patient care areas
that are acuity adaptable or acuity adjustable shall
apply the direct care registered nurse-to-patient ratio
required in this section for the highest patient acuity
level or level of care in that unit or patient care
area, and shall comply with all other requirements of
this section.
``(E) Use of video monitors.--A hospital shall not
employ video monitors or any form of electronic
visualization of a patient as a substitute for the
direct observation required for patient assessment by
the direct care registered nurse or required for
patient protection. Video monitors or any form of
electronic visualization of a patient shall not be
included in the calculation of the direct care
registered nurse-to-patient ratio required in this
subsection and shall not replace the requirement of
paragraph (3)(D) that each patient shall be assigned to
a direct care registered nurse who shall directly
provide the assessment, planning, supervision,
implementation, and evaluation of the nursing care
provided to the patient at least every shift and have
the responsibility for the provision of care to a
particular patient within his or her scope of practice.
``(F) Use of other technology.--A hospital shall
not employ technology that substitutes for the assigned
registered nurse's professional judgment in assessment,
planning, implementation, and evaluation of care.
``(5) Adjustment of ratios.--
``(A) In general.--If necessary to protect patient
safety, the Secretary may prescribe regulations that--
``(i) increase minimum direct care
registered nurse-to-patient ratios under this
subsection to reduce the number of patients
that may be assigned to each direct care nurse;
or
``(ii) add minimum direct care registered
nurse-to-patient ratios for units not referred
to in paragraphs (1) and (2).
``(B) Consultation.--Such regulations shall be
prescribed after consultation with affected hospitals
and registered nurses.
``(6) Ancillary and additional staffing.--
``(A) In general.--The Secretary may prescribe
regulations requiring additional staffing of direct
care registered nurses, licensed vocational or practice
nurses, licensed psychiatric technicians, certified
nursing or patient care assistants, or other licensed
or unlicensed ancillary staff above the minimum
registered nurse-to-patient ratios that is based on the
assessment of the individual patient's nursing care
needs, the individual patient's nursing care plan, and
acuity level.
``(B) Consultation.--Such regulations shall be
prescribed after consultation with affected hospitals,
registered nurses, and ancillary staff.
``(7) Relationship to state-imposed ratios.--Nothing in
this title shall preempt State standards that the Secretary
determines to be as stringent as Federal requirements for a
staffing plan established under this title. Minimum direct care
registered nurse-to-patient ratios established under this
subsection shall not preempt State requirements that the
Secretary determines are as stringent as to Federal
requirements for direct care registered nurse-to-patient ratios
established under this title.
``(8) Exemption in emergencies.--The requirements
established under this subsection shall not apply during a
state of emergency if a hospital is requested or expected to
provide an exceptional level of emergency or other medical
services. If a hospital seeks to apply the exemption under this
paragraph in response to a complaint filed against the hospital
for a violation of the provisions of this title, the hospital
must demonstrate that prompt and diligent efforts were made to
maintain required staffing levels. The Secretary shall issue
guidance to hospitals that describes situations that constitute
a state of emergency for purposes of the exemption under this
paragraph and shall establish necessary penalties for
violations of this paragraph consistent with section 3406.
``(c) Development and Reevaluation of Staffing Plan.--
``(1) Considerations in development of plan.--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, at
minimum, the following factors:
``(A) The number of patients on a particular unit
on a shift-by-shift basis.
``(B) The acuity level and nursing care plan of
patients on a particular unit on a shift-by-shift
basis.
``(C) The anticipated admissions, discharges, and
transfers of patients during each shift that impacts
direct patient care.
``(D) Specialized experience required of direct
care registered nurses on a particular unit.
``(E) 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.
``(F) The level of familiarity with hospital
practices, policies, and procedures by temporary agency
direct care registered nurses used during a shift.
``(G) Obstacles to efficiency in the delivery of
patient care presented by physical layout.
``(2) Documentation of staffing.--A hospital shall specify
the system used to document actual staffing in each unit for
each shift.
``(3) Annual reevaluation of plan.--
``(A) In general.--A hospital shall annually
evaluate its staffing plan in each unit in relation to
actual patient care requirements.
``(B) Update.--A hospital shall update its staffing
plan to the extent appropriate based on such
evaluation.
``(4) Transparency.--
``(A) In general.--Any staffing plan or method used
to create and evaluate acuity-level and adopted by a
hospital under this section shall be transparent in all
respects, including disclosure of detailed
documentation of the methodology used to determine
nursing staffing, identifying each factor, assumption,
and value used in applying such methodology.
``(B) Public availability.--The Secretary shall
establish procedures to provide that the documentation
submitted under subsection (d) is available for public
inspection in its entirety.
``(5) Registered nurse participation.--A staffing plan of a
hospital--
``(A) shall be developed and subsequent
reevaluations shall be conducted under this subsection
on the basis of input from direct care registered
nurses at the hospital from each unit or patient care
area; and
``(B) where such nurses are represented through
collective bargaining, shall require bargaining with
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 (29 U.S.C.
151 et seq.) or chapter 71 of title 5, United States Code.
``(6) Staffing committees.--If a hospital maintains a
staffing committee, then the committee shall include at least
one registered nurse from each hospital unit and shall be
composed of at least 50 percent direct care registered nurses.
The staffing committee shall include meaningful representation
of other direct care nonmanagement staff. Direct care
registered nurses who serve on the committee shall be selected
by other direct care registered nurses from their unit. Other
direct care nonmanagement staff shall be selected by other
direct care nonmanagement staff. Participation on staffing
committees shall be considered a part of the employee's
regularly scheduled workweek.
``(d) Submission of Plan to Secretary.--A hospital shall submit to
the Secretary its staffing plan and any annual updates under subsection
(c)(3)(B). A federally operated hospital may submit its staffing plan
through the department or agency operating the hospital.
``SEC. 3402. POSTING, RECORDS, AND AUDITS.
``(a) Posting Requirements.--In each unit, a hospital shall post a
uniform notice in a form specified by the Secretary in regulation
that--
``(1) explains requirements imposed under section 3401;
``(2) includes actual direct care registered nurse-to-
patient ratios during each shift;
``(3) includes the actual number and titles of direct care
registered nurses assigned during each shift; and
``(4) is visible, conspicuous, and accessible to staff,
patients, and the public.
``(b) Records.--
``(1) Maintenance of records.--Each hospital shall maintain
accurate records of actual direct care registered nurse-to-
patient ratios in each unit for each shift for no less than 3
years. Such records shall include--
``(A) the number of patients in each unit;
``(B) the identity and duty hours of--
``(i) each direct care registered nurse
assigned to each patient in each unit in each
shift; and
``(ii) ancillary staff who are under the
coordination of the direct care registered
nurse;
``(C) certification that each nurse received rest
and meal breaks and the identity and duty hours of each
direct care registered nurse who provided such relief;
and
``(D) a copy of each notice posted under subsection
(a).
``(2) Availability of records.--Each hospital shall make
its records maintained under paragraph (1) available to--
``(A) the Secretary;
``(B) registered nurses and their collective
bargaining representatives (if any); and
``(C) 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).
``(c) Audits.--The Secretary shall conduct periodic audits to
ensure--
``(1) implementation of the staffing plan in accordance
with this title; and
``(2) accuracy in records maintained under this section.
``SEC. 3403. MINIMUM DIRECT CARE LICENSED PRACTICAL NURSE STAFFING
REQUIREMENTS.
``(a) Establishment.--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 the enactment of this title, and shall be based on the study
conducted under subsection (b).
``(b) Study.--Not later than 1 year after the date of the 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.
``(c) Application of Registered Nurse Provisions to Licensed
Practical Nurse Staffing Requirements.--Paragraphs (2), (4)(A), (4)(B),
(4)(C), and (6) of section 3401(b), paragraphs (1), (2), (3), and (4)
of section 3401(c), and section 3402 shall apply to the establishment
and application of direct care licensed practical nurse staffing
requirements under this section pursuant to the additional staffing
requirements under subsection (b)(3)(G) of section 3401 and 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.
``(d) Effective Date.--The requirements of this section shall take
effect as soon as practicable, as determined by the Secretary, but not
later than--
``(1) 2 years after the date of the enactment of this
title; and
``(2) in the case of a hospital in a rural area (as defined
in section 1886(d)(2)(D) of the Social Security Act), 4 years
after the date of the enactment of this title.
``(e) Study.--Not later than 1 year after the date of the enactment
of this title, the Secretary, acting through the Director of the Agency
for Healthcare Research and Quality, shall complete a study of
registered and practical nurse staffing requirements in clinics and
other outpatient settings, and its effects on patient care in
outpatient settings. The Director may contract with a qualified entity
or organization to carry out such study under this subsection. The
Director shall consult with registered nurses and licensed practice
nurses working in outpatient settings, including professional nursing
associations and labor organizations representing both registered and
practice nurses working in outpatient settings regarding the design and
conduct of the study.
``SEC. 3404. ADJUSTMENT IN REIMBURSEMENT.
``(a) Medicare Reimbursement.--The Secretary shall adjust payments
made to hospitals (other than federally operated 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 (c).
``(b) Authorization of Appropriation for Federally Operated
Hospitals.--There are authorized to be appropriated such additional
sums as are required for federally operated hospitals to comply with
the additional requirements established under sections 3401 through
3403.
``(c) MedPAC Report.--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).
``SEC. 3405. WHISTLEBLOWER AND PATIENT PROTECTIONS.
``(a) Professional Obligation and Rights.--All nurses have a duty
and right to act based on their professional judgment in accordance
with State nursing laws and regulations of the State in which the
direct nursing care is being performed and to provide care in the
exclusive interests of the patients and to act as the patient's
advocate.
``(b) Acceptance of Patient Care Assignments.--The nurse is
responsible for providing competent, safe, therapeutic, and effective
nursing care to assigned patients. Before accepting a patient
assignment, a nurse shall--
``(1) have the necessary professional knowledge, judgment,
skills, and ability to provide the required care;
``(2) determine using professional judgment in accordance
with State nursing laws and regulations of the State in which
the direct nursing care is being performed whether the nurse is
competent to perform the nursing care required; and
``(3) determine whether acceptance of a patient assignment
would expose the patient or nurse to risk of harm.
``(c) Objection to or Refusal of Assignment.--A nurse may object
to, or refuse to participate in, any activity, policy, practice,
assignment, or task if in good faith--
``(1) the nurse reasonably believes it to be in violation
of section 3401 or 3403; or
``(2) 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.
``(d) Retaliation for Objection to or Refusal of Assignment
Barred.--
``(1) No discharge, discrimination, or retaliation.--No
hospital shall discharge, retaliate, discriminate, or otherwise
take adverse action in any manner with respect to any aspect of
a nurse's employment (as defined in section 3407), including
discharge, promotion, compensation, or terms, conditions, or
privileges of employment, based on the nurse's refusal of a
work assignment under subsection (c).
``(2) No filing of complaint.--No hospital shall file a
complaint or a report against a nurse with a State professional
disciplinary agency because of the nurse's refusal of a work
assignment under subsection (c).
``(e) Cause of Action.--Any nurse, collective bargaining
representative, or legal representative of any nurse who has been
discharged, discriminated against, or retaliated against in violation
of subsection (d)(1) or against whom a complaint or report has been
filed in violation of subsection (d)(2) may (without regard to whether
a complaint has been filed under subsection (f) of this section or
subsection (b) of section 3406) 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:
``(1) Reinstatement.
``(2) Reimbursement of lost wages, compensation, and
benefits.
``(3) Attorneys' fees.
``(4) Court costs.
``(5) Other damages.
``(f) Complaint to Secretary.--A nurse, patient, collective
bargaining representative, 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--
``(1) receive and investigate the complaint;
``(2) determine whether a violation of this title as
alleged in the complaint has occurred; and
``(3) if such a violation has occurred, issue an order that
the complaining nurse or individual shall not suffer any
discharge, retaliation, discrimination, or other adverse action
prohibited by subsection (d) or subsection (h).
``(g) Toll-Free Telephone Number.--
``(1) In general.--The Secretary shall provide for the
establishment of a toll-free telephone hotline to provide
information regarding the requirements under section 3401
through 3403 and to receive reports of violations of such
section.
``(2) Notice to patients.--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.
``(h) Protection for Reporting.--
``(1) Prohibition on retaliation or discrimination.--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.
``(2) Good faith defined.--For purposes of this subsection,
an individual shall be deemed to be acting in good faith if the
individual reasonably believes--
``(A) the information reported or disclosed is
true; and
``(B) a violation of this title has occurred or may
occur.
``(i) Prohibition on Interference With Rights.--
``(1) Exercise of rights.--It shall be unlawful for any
hospital to--
``(A) interfere with, restrain, or deny the
exercise, or attempt to exercise, by any person of any
right provided or protected under this title; or
``(B) coerce or intimidate any person regarding the
exercise or attempt to exercise such right.
``(2) Opposition to unlawful policies or practices.--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.
``(3) Prohibition on interference with protected
communications.--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
nurse from, or intimidates, coerces, or induces a direct care
nurse regarding, engaging in free speech activities or
disclosing information as provided under this title.
``(4) Prohibition on interference with collective action.--
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).
``(j) Notice.--A hospital shall post in an appropriate location in
each unit a conspicuous notice in a form specified by the Secretary
that--
``(1) explains the rights of nurses, patients, and other
individuals under this section;
``(2) 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
``(3) provides instructions on how to file such a
complaint.
``(k) Effective Date.--
``(1) Refusal; retaliation; cause of action.--
``(A) In general.--Subsections (c) through (e)
shall apply to objections and refusals occurring on or
after the effective date of the provision of this title
to which the objection or refusal relates.
``(B) Exception.--Subsection (c)(2) shall not apply
to objections or refusals in any hospital before the
requirements of section 3401(a) or 3403(a), as
applicable, apply to that hospital.
``(2) Protections for reporting.--Subsection (h)(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.
``(3) Notice.--Subsection (j) shall take effect 18 months
after the date of enactment of this title.
``SEC. 3406. ENFORCEMENT.
``(a) In General.--The Secretary shall enforce the requirements and
prohibitions of this title in accordance with this section.
``(b) Procedures for Receiving and Investigating Complaints.--The
Secretary shall establish procedures under which--
``(1) any person may file a complaint alleging that a
hospital has violated a requirement or a prohibition of this
title; and
``(2) such complaints shall be investigated by the
Secretary.
``(c) Remedies.--If the Secretary determines that a hospital has
violated a requirement of this title, the Secretary--
``(1) shall require the facility to establish a corrective
action plan to prevent the recurrence of such violation; and
``(2) may impose civil money penalties, as described in
subsection (d).
``(d) Civil Penalties.--
``(1) In general.--In addition to any other penalties
prescribed by law, the Secretary may impose civil penalties as
follows:
``(A) Hospital liability.--The Secretary may impose
on a hospital found to be in violation of this title a
civil money penalty of--
``(i) not more than $25,000 for the first
knowing violation of this title by such
hospital; and
``(ii) not more than $50,000 for any
subsequent knowing violation of this title by
such hospital.
``(B) Individual liability.--The Secretary may
impose on an individual who--
``(i) is employed by a hospital found by
the Secretary to have violated this title; and
``(ii) knowingly violates this title,
a civil money penalty of not more than $20,000 for each
such violation by the individual.
``(2) Procedures.--The provisions of section 1128A of the
Social Security Act (other than subsections (a) and (b)) shall
apply with respect to a civil money penalty or proceeding under
this subsection in the same manner as such provisions apply
with respect to a civil money penalty or proceeding under such
section 1128A.
``(e) Public Notice of Violations.--
``(1) Internet website.--The Secretary shall publish on the
internet website of the Department of Health and Human Services
the names of hospitals on which a civil money penalty has been
imposed under this section, the violation for which such
penalty was imposed, and such additional information as the
Secretary determines appropriate.
``(2) Change of ownership.--With respect to a hospital that
had a change of ownership, as determined by the Secretary,
penalties imposed on the hospital while under previous
ownership shall no longer be published by the Secretary
pursuant to paragraph (1) after the 1-year period beginning on
the date of change of ownership.
``(f) Use of Funds.--Funds collected by the Secretary pursuant to
this section are authorized to be appropriated to carry out this title.
``SEC. 3407. DEFINITIONS.
``For purposes of this title:
``(1) Acuity level.--The term `acuity level' means the
determination, using a hospital acuity measurement tool that
has been developed and established in coordination with direct
care registered nurses and made transparent pursuant to section
3401(c)(4), of nursing care requirements, based on the assigned
direct care registered nurse's professional judgment of--
``(A) the severity and complexity of an individual
patient's illness or injury;
``(B) the need for specialized equipment; and
``(C) the intensity of nursing interventions
required.
``(2) Competence.--The term `competence' or `competent'
means the satisfactory application of the duties and
responsibilities of a registered nurse in providing nursing
care to specific patient populations and for acuity levels for
each patient care unit or area pursuant to the State nursing
laws and regulations of the State in which the direct nursing
care is being performed.
``(3) Direct care licensed practical nurse.--The term
`direct care licensed practical nurse' means an individual who
has been granted a license by at least one State to practice as
a licensed practical nurse or a licensed vocational nurse and
who provides bedside care for one or more patients.
``(4) Direct care registered nurse.--The term `direct care
registered nurse' means an individual who has been granted a
license by at least one State to practice as a registered nurse
and who provides bedside care for one or more patients.
``(5) Employment.--The term `employment' includes the
provision of services under a contract or other arrangement.
``(6) Hospital.--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, the Department of Defense, the Indian Health
Services Program, or any other department or agency of the
United States.
``(7) Nurse.--The term `nurse' means any direct care
registered nurse or direct care licensed practice nurse (as the
case may be), regardless of whether or not the nurse is an
employee.
``(8) Nursing care plan.--The term `nursing care plan'
means a plan developed by the assigned direct care registered
nurse (in accordance with nursing law in the State in which the
nursing care is performed) that indicates the nursing care to
be given to individual patients that--
``(A) considers the acuity level of the patient;
``(B) is developed in coordination with the
patient, the patient's family, or other representatives
when appropriate, and staff of other disciplines
involved in the care of the patient;
``(C) reflects all elements of the nursing process;
and
``(D) recommends the number and skill mix of
additional licensed and unlicensed direct care staff
needed to fully implement the nursing care plan.
``(9) Professional judgment.--The term `professional
judgment' means, in accordance with State nursing laws and
regulations of the State in which the direct nursing care is
being performed, the direct care registered nurse's application
of knowledge, expertise, and experience in conducting a
comprehensive nursing assessment of each patient and in making
independent decisions about patient care including the need for
additional staff.
``(10) Staffing plan.--The term `staffing plan' means a
staffing plan required under section 3401.
``(11) State of emergency.--The term `state of emergency'--
``(A) 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; and
``(B) does not include a state of emergency that
results from a labor dispute in the health care
industry or consistent understaffing.
``SEC. 3408. RULE OF CONSTRUCTION.
``Nothing in this title shall be construed to authorize disclosure
of private and confidential patient information, if such disclosure is
not authorized or required by other applicable law.''.
(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).
SEC. 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) in subparagraph (X), by striking ``, and'' and
inserting a comma;
(2) in subparagraph (Y), by striking the period at the end
and inserting ``, and''; and
(3) by inserting after the subparagraph (Y) the following
new subparagraph:
``(Z) in the case of a hospital, to comply with 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) by striking ``and'' at the end of paragraph (86);
(2) by striking the period at the end of paragraph (87)(D)
and inserting ``; and''; and
(3) by inserting after paragraph (87) the following new
paragraph:
``(88) provide that any hospital that receives a payment
under such plan comply with the provisions of title XXXIV of
the Public Health Service Act (relating to minimum direct care
registered nurse staffing requirements).''.
(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 new paragraphs:
``(7) In the case of a Department medical facility that is a
hospital, the 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 hospital
through grievance procedures negotiated in accordance with chapter 71
of title 5.''.
(d) Health Benefits Program of the Department of Defense.--
(1) In general.--Chapter 55 of title 10, United States
Code, is amended by adding at the end the following new
section:
``Sec. 1110c. Staffing requirements
``In the case of a facility of the uniformed services that is a
hospital, the hospital shall comply with the provisions of title XXXIV
of the Public Health Service Act.''.
(2) Clerical amendment.--The table of sections at the
beginning of such chapter is amended by inserting after the
item relating to section 1110b the following new item:
``1110c. Staffing requirements.''.
(e) Indian Health Services Program.--Title VIII of the Indian
Health Care Improvement Act (25 U.S.C. 1671 et seq.) is amended by
adding at the end the following new section:
``SEC. 833. STAFFING REQUIREMENTS.
``All hospitals of the Service shall comply with the provisions of
title XXXIV of the Public Health Service Act (relating to minimum
direct care registered nurse staffing requirements).''.
(f) Federal Labor-Management Relations.--
(1) In general.--Section 7106 of title 5, United States
Code, is amended by adding at the end the following:
``(c) Nothing in this section shall preclude enforcement of the
provisions of title XXXIV of the Public Health Service Act through
grievance procedures negotiated in accordance with section 7121.''.
(2) Conforming amendment.--Section 7106(a) of title 5,
United States Code, is amended by striking ``Subject to
subsection (b) of this section,'' and inserting ``Subject to
subsections (b) and (c),''.
SEC. 4. NURSE WORKFORCE INITIATIVE.
(a) Scholarship and Stipend Program.--Subsection (d) of section 846
of the Public Health Service Act (42 U.S.C. 297n) is amended--
(1) in the subsection heading, by inserting ``and Stipend''
after ``Scholarship''; and
(2) in paragraph (1), by inserting ``or stipends'' after
``scholarships''.
(b) Nurse Retention Grants.--Section 831(c)(1) of the Public Health
Service Act (42 U.S.C. 296p(c)(1)) is amended--
(1) by striking ``Grants for career ladder programs'' and
inserting ``Grants for nurse retention'';
(2) in subparagraph (B), by striking ``; and'' and
inserting a semicolon;
(3) in subparagraph (C), by striking the period at the end
and inserting a semicolon; and
(4) by adding at the end the following:
``(D) 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 program for
registered nurses; and
``(E) to implement mentorship projects that assist
new or transitional direct care registered nurses in
adapting to the hospital setting.''.
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