[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5052 Introduced in House (IH)]
<DOC>
115th CONGRESS
2d Session
H. R. 5052
To amend title XVIII of the Social Security Act to provide for patient
protection by establishing safe nurse staffing levels at certain
Medicare providers, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
February 15, 2018
Mr. Joyce of Ohio (for himself, Ms. DelBene, Ms. Gabbard, and Ms.
Bonamici) 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 title XVIII of the Social Security Act to provide for patient
protection by establishing safe nurse staffing levels at certain
Medicare providers, 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.
This Act may be cited as the ``Safe Staffing for Nurse and Patient
Safety Act of 2018''.
SEC. 2. FINDINGS.
Congress makes the following findings:
(1) The overwhelming weight of academic research continues
to demonstrate that patient safety, prevention of medication
errors, failure to rescue situations, patient deterioration,
patient death, and nurse burnout are all proportionate to the
number of nurses staffed in a hospital. Therefore, higher
staffing levels by experienced registered nurses are associated
with lower rates of negative patient outcomes and costs.
(2) Proper nurse staffing decreases the rate of patients'
hospital readmissions. Medicare does not pay hospitals for
patients who are readmitted for the same condition within 30
days. In 2013, 17.5 percent of Medicare beneficiaries were
readmitted to a hospital within 30 days following discharge.
These readmissions cost Medicare an estimated $26,000,000,000
per year. The research indicates, however, that proper nurse
staffing reduces such readmissions and pays for itself over the
long term.
(3) The 2015 National Healthcare Retention and RN Staffing
Report revealed that nurse turnover costs the average U.S.
hospital nearly $5,000,000 every year. Appropriate nurse
staffing reduces nurse burnout and turnover, saving hospitals
money.
(4) Proper nurse staffing helps prevent medication errors
and nurse burnout through decreasing healthcare worker fatigue.
Healthcare worker fatigue is a major patient safety hazard. The
academic literature indicates that appropriate staffing
policies and practices are an effective strategy to reducing
such fatigue and protecting patients.
(5) Research shows that optimal nurse staffing and skill
mix improves patient satisfaction, and results in savings to
hospitals through reductions in negative, adverse patient
events. Improved patient satisfaction due to appropriate nurse
staffing is reflected in hospitals' patient satisfaction survey
results, which are publicly reported, and are a key measure for
value-based payment programs.
(6) Research indicates that patients who receive care
during periods of sub-optimal nurse staffing experience
increased rates of medication errors, increased rates of death,
increased rates of failure-to-rescue, and worse outcomes.
(7) As a payor for inpatient and outpatient hospital
services furnished to Medicare beneficiaries, the Federal
Government has a compelling interest in promoting the safety of
hospitalized patients by requiring any hospital participating
in the Medicare program to establish appropriate registered
nurse staffing levels.
SEC. 3. ESTABLISHMENT OF SAFE NURSE STAFFING LEVELS BY MEDICARE
PARTICIPATING HOSPITALS.
(a) Requirement of Medicare Provider Agreement.--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 (X);
(2) by striking the period at the end of subparagraph (Y)
and inserting ``, and''; and
(3) by inserting after subparagraph (Y) the following new
subparagraph:
``(Z) in the case of a hospital (as defined in section
1861(e)), to meet the requirements of section 1899C.''.
(b) Requirements.--Title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.) is amended by adding at the end the following new
section:
``nurse staffing requirements for medicare participating hospitals
``Sec. 1899C. (a) Implementation of Nurse Staffing Plan.--
``(1) In general.--Subject to paragraph (3), each
participating hospital shall implement a hospital-wide staffing
plan for nursing services furnished in the hospital.
``(2) Requirement for development of staffing plan by
hospital nurse staffing committee.--The hospital-wide staffing
plan for nursing services implemented by a hospital pursuant to
paragraph (1)--
``(A) shall be developed by the hospital nurse
staffing committee established under subsection (b);
and
``(B) shall require that an appropriate number of
registered nurses provide direct patient care in each
unit and on each shift of the hospital to ensure
staffing levels that--
``(i) address the unique characteristics of
the patients and hospital units; and
``(ii) result in the delivery of safe,
quality patient care, consistent with the
requirements under subsection (c).
``(b) Hospital Nurse Staffing Committee.--
``(1) Establishment.--Each participating hospital shall
establish a hospital nurse staffing committee (in this section
referred to as the `Committee').
``(2) Composition.--A Committee established pursuant to
this subsection shall be composed of members as follows:
``(A) Minimum 55 percent nurse participation.--Not
less than 55 percent of the members of the Committee
shall be registered nurses who provide direct patient
care but who are neither hospital nurse managers nor
part of the hospital administration staff.
``(B) Inclusion of hospital nurse managers.--The
Committee shall include members who are hospital nurse
managers.
``(C) Inclusion of nurses from specialty units.--
The members of the Committee shall include at least 1
registered nurse who provides direct care from each
nurse specialty or unit of the hospital (each such
specialty or unit as determined by the hospital).
``(D) Other hospital personnel.--The Committee
shall include such other personnel of the hospital as
the hospital determines to be appropriate.
``(3) Duties.--
``(A) Development of staffing plan.--The Committee
shall develop a hospital-wide staffing plan for nursing
services furnished in the hospital consistent with the
requirements under subsection (c).
``(B) Review and modification of staffing plan.--
The Committee shall--
``(i) conduct regular, ongoing monitoring
of the implementation of the hospital-wide
staffing plan for nursing services furnished in
the hospital;
``(ii) carry out evaluations of the
hospital-wide staffing plan for nursing
services at least annually; and
``(iii) make such modifications to the
hospital-wide staffing plan for nursing
services as may be appropriate.
``(C) Additional duties.--The Committee shall--
``(i) develop policies and procedures for
overtime requirements of registered nurses
providing direct patient care and for
appropriate time and manner of relief of such
registered nurses during routine absences; and
``(ii) carry out such additional duties as
the Committee determines to be appropriate.
``(c) Staffing Plan Requirements.--
``(1) Plan requirements.--Subject to paragraph (2), a
hospital-wide staffing plan for nursing services developed and
implemented under this section shall--
``(A) be based upon input from the registered nurse
staff of the hospital who provide direct patient care
or their exclusive representatives, as well as the
chief nurse executive;
``(B) be based upon the number of patients and the
level and variability of intensity of care to be
provided to those patients, with appropriate
consideration given to admissions, discharges, and
transfers during each shift;
``(C) take into account contextual issues affecting
nurse staffing and the delivery of care, including
architecture and geography of the environment and
available technology;
``(D) take into account the level of education,
training, and experience of those registered nurses
providing direct patient care;
``(E) take into account the staffing levels and
services provided by other health care personnel
associated with nursing care, such as certified nurse
assistants, licensed vocational nurses, licensed
psychiatric technicians, nursing assistants, aides, and
orderlies;
``(F) take into account staffing levels recommended
by specialty nursing organizations;
``(G) establish upwardly adjustable minimum ratios
of direct care registered nurses to patients for each
unit and for each shift of the hospital, based upon an
assessment by registered nurses of the level and
variability of intensity of care required by patients
under existing conditions;
``(H) take into account unit and facility level
staffing, quality and patient outcome data, and
national comparisons, as available;
``(I) ensure that a registered nurse shall not be
assigned to work in a particular unit of the hospital
without first having established the ability to provide
professional care in such unit; and
``(J) provide for exemptions from some or all
requirements of the hospital-wide staffing plan for
nursing services during a declared state of emergency
(as defined in subsection (l)(1)) if the hospital is
requested or expected to provide an exceptional level
of emergency or other medical services.
``(2) Limitation.--A hospital-wide staffing plan for
nursing services developed and implemented under this section--
``(A) shall not preempt any registered-nurse
staffing levels established under State law or
regulation; and
``(B) may not utilize any minimum number of
registered nurses established under paragraph (1)(G) as
an upper limit on the nurse staffing of the hospital to
which such minimum number applies.
``(d) Reporting and Release to Public of Certain Staffing
Information.--
``(1) Requirements for hospitals.--Each participating
hospital shall--
``(A) post daily for each shift, in a clearly
visible place, a document that specifies in a uniform
manner (as prescribed by the Secretary) the current
number of licensed and unlicensed nursing staff
directly responsible for patient care in each unit of
the hospital, identifying specifically the number of
registered nurses;
``(B) upon request, make available to the public--
``(i) the nursing staff information
described in subparagraph (A);
``(ii) a detailed written description of
the hospital-wide staffing plan implemented by
the hospital pursuant to subsection (a); and
``(iii) not later than 90 days after the
date on which an evaluation is carried out by
the Committee under subsection (b)(3)(B)(ii), a
copy of such evaluation; and
``(C) not less frequently than quarterly, submit to
the Secretary in a uniform manner (as prescribed by the
Secretary) the nursing staff information described in
subparagraph (A) through electronic data submission.
``(2) Secretarial responsibilities.--The Secretary shall--
``(A) make the information submitted pursuant to
paragraph (1)(C) publicly available in a comprehensible
format (as described in subsection (e)(2)(D)(ii)),
including by publication on the Hospital Compare
Internet Web site of the Department of Health and Human
Services; and
``(B) provide for the auditing of such information
for accuracy as a part of the process of determining
whether the participating hospital is in compliance
with the conditions of its agreement with the Secretary
under section 1866, including under subsection
(a)(1)(Y) of such section.
``(e) Recordkeeping; Collection and Reporting of Quality Data;
Evaluation.--
``(1) Recordkeeping.--Each participating hospital shall
maintain for a period of at least 3 years (or, if longer, until
the conclusion of any pending enforcement activities) such
records as the Secretary deems necessary to determine whether
the hospital has implemented a hospital-wide staffing plan for
nursing services pursuant to subsection (a).
``(2) Collection and reporting of quality data on nursing
services.--
``(A) In general.--The Secretary shall require the
collection, aggregation, maintenance, and reporting of
quality data relating to nursing services furnished by
each participating hospital.
``(B) Use of endorsed measures.--In carrying out
this paragraph, the Secretary shall use only quality
measures for nursing-sensitive care that are endorsed
by the consensus-based entity with a contract under
section 1890(a).
``(C) Use of qualified third-party entities for
collection and submission of data.--
``(i) In general.--A participating hospital
may enter into agreements with third-party
entities that have demonstrated expertise in
the collection and submission of quality data
on nursing services to collect, aggregate,
maintain, and report the quality data of the
hospital pursuant to subparagraph (A).
``(ii) Construction.--Nothing in clause (i)
shall be construed to excuse or exempt a
participating hospital that has entered into an
agreement described in such clause from
compliance with requirements for quality data
collection, aggregation, maintenance, and
reporting imposed under this paragraph.
``(D) Reporting of quality data.--
``(i) Publication on hospital compare web
site.--Subject to the succeeding provisions of
this subparagraph, the Secretary shall make the
data submitted pursuant to subparagraph (A)
publicly available, including by publication on
the Hospital Compare Internet Web site of the
Department of Health and Human Services.
``(ii) Comprehensible format.--Data made
available to the public under clause (i) shall
be presented in a clearly understandable format
that permits consumers of hospital services to
make meaningful comparisons among hospitals,
including concise explanations in plain English
of how to interpret the data, of the difference
in types of nursing staff, of the relationship
between nurse staffing levels and quality of
care, and of how nurse staffing may vary based
on patient case mix.
``(iii) Opportunity to correct errors.--The
Secretary shall establish a process under which
participating hospitals may review data
submitted to the Secretary pursuant to
subparagraph (A) to correct errors, if any,
contained in that data submission before making
the data available to the public under clause
(i).
``(3) Evaluation of data.--The Secretary shall provide for
the analysis of quality data collected from participating
hospitals under paragraph (2) in order to evaluate the effect
of hospital-wide staffing plans for nursing services
implemented pursuant to subsection (a) on--
``(A) patient outcomes that are nursing sensitive
(such as pressure ulcers, fall occurrence, falls
resulting in injury, length of stay, and central line
catheter infections); and
``(B) nursing workforce safety and retention
(including work-related injury, staff skill mix,
nursing care hours per patient day, vacancy and
voluntary turnover rates, overtime rates, use of
temporary agency personnel, and nurse satisfaction).
``(f) Refusal of Assignment.--A nurse may refuse to accept an
assignment as a nurse in a participating hospital, or in a unit of a
participating hospital, if--
``(1) the assignment is in violation of the hospital-wide
staffing plan for nursing services implemented pursuant to
subsection (a); 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.
``(g) Enforcement.--
``(1) Responsibility.--The Secretary shall enforce the
requirements and prohibitions of this section in accordance
with the succeeding provisions of this subsection.
``(2) Procedures for receiving and investigating
complaints.--The Secretary shall establish procedures under
which--
``(A) any person may file a complaint that a
participating hospital has violated a requirement of or
a prohibition under this section; and
``(B) such complaints are investigated by the
Secretary.
``(3) Remedies.--Except as provided in paragraph (5), if
the Secretary determines that a participating hospital has
violated a requirement of this section, the Secretary--
``(A) shall require the hospital to establish a
corrective action plan to prevent the recurrence of
such violation; and
``(B) may impose civil money penalties under
paragraph (4).
``(4) Civil money penalties.--
``(A) In general.--In addition to any other
penalties prescribed by law, the Secretary may impose a
civil money penalty of not more than $10,000 for each
knowing violation of a requirement of this section,
except that the Secretary shall impose a civil money
penalty of more than $10,000 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).
``(B) Procedures.--The provisions of section 1128A
(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 section 1128A.
``(C) Public notice of violations.--
``(i) Internet web site.--The Secretary
shall publish on an appropriate Internet Web
site of the Department of Health and Human
Services the names of participating hospitals
on which civil money penalties have been
imposed under this section, the violation for
which the penalty was imposed, and such
additional information as the Secretary
determines appropriate.
``(ii) Change of ownership.--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 Web site
after the 1-year period beginning on the date
of the change in ownership.
``(5) Penalty for failure to collect and report quality
data on nursing services.--
``(A) In general.--In the case of a participating
hospital that fails to comply with requirements under
subsection (e)(2) to collect, aggregate, maintain, and
report quality data relating to nursing services
furnished by the hospital, instead of the remedies
described in paragraph (3), the provisions of
subparagraph (B) shall apply with respect to each such
failure of the participating hospital.
``(B) Penalty.--In the case of a failure by a
participating hospital to comply with the requirements
under subsection (e)(2) for a year, each such failure
shall be deemed to be a failure to submit data required
under section 1833(t)(17)(A), section
1886(b)(3)(B)(viii), section 1886(j)(7)(A), or section
1886(m)(5)(A), as the case may be, with respect to the
participating hospital involved for that year.
``(h) Whistleblower Protections.--
``(1) Prohibition of discrimination and retaliation.--A
participating hospital shall not discriminate or retaliate in
any manner against any patient or employee of the hospital
because that patient or employee, or any other person, has
presented a grievance or complaint, or has initiated or
cooperated in any investigation or proceeding of any kind,
relating to--
``(A) the hospital-wide staffing plan for nursing
services developed and implemented under this section;
or
``(B) any right, other requirement or prohibition
under this section, including a refusal to accept an
assignment described in subsection (f).
``(2) Relief for prevailing employees.--An employee of a
participating hospital who has been discriminated or retaliated
against in employment in violation of this subsection may
initiate judicial action in a United States district court and
shall be entitled to reinstatement, reimbursement for lost
wages, and work benefits caused by the unlawful acts of the
employing hospital. Prevailing employees are entitled to
reasonable attorney's fees and costs associated with pursuing
the case.
``(3) Relief for prevailing patients.--A patient who has
been discriminated or retaliated against in violation of this
subsection may initiate judicial action in a United States
district court. A prevailing patient shall be entitled to
liquidated damages of $5,000 for a violation of this statute in
addition to any other damages under other applicable statutes,
regulations, or common law. Prevailing patients are entitled to
reasonable attorney's fees and costs associated with pursuing
the case.
``(4) Limitation on actions.--No action may be brought
under paragraph (2) or (3) more than 2 years after the
discrimination or retaliation with respect to which the action
is brought.
``(5) Treatment of adverse employment actions.--For
purposes of this subsection--
``(A) an adverse employment action shall be treated
as discrimination or retaliation; and
``(B) the term `adverse employment action'
includes--
``(i) the failure to promote an individual
or provide any other employment-related benefit
for which the individual would otherwise be
eligible;
``(ii) an adverse evaluation or decision
made in relation to accreditation,
certification, credentialing, or licensing of
the individual; and
``(iii) a personnel action that is adverse
to the individual concerned.
``(i) Relationship to State Laws.--Nothing in this section shall be
construed as exempting or relieving any person from any liability,
duty, penalty, or punishment provided by the law of any State or
political subdivision of a State, other than any such law which
purports to require or permit any action prohibited under this title.
``(j) Relationship to Conduct Prohibited Under the National Labor
Relations Act or Other Collective Bargaining Laws.--Nothing in this
section shall be construed as--
``(1) permitting conduct prohibited under the National
Labor Relations Act or under any other Federal, State, or local
collective bargaining law; or
``(2) preempting, limiting, or modifying a collective
bargaining agreement entered into by a participating hospital.
``(k) Regulations.--
``(1) In general.--The Secretary shall promulgate such
regulations as are appropriate and necessary to implement this
section.
``(2) Implementation.--
``(A) In general.--Except as provided in
subparagraph (B), as soon as practicable but not later
than 2 years after the date of the enactment of this
section, a participating hospital shall have
implemented a hospital-wide staffing plan for nursing
services under this section.
``(B) Special rule for rural hospitals.--In the
case of a participating hospital located in a rural
area (as defined in section 1886(d)(2)(D)), such
participating hospital shall have implemented a
hospital-wide staffing plan for nursing services under
this section as soon as practicable but not later than
4 years after the date of the enactment of this
section.
``(l) Definitions.--In this section:
``(1) Declared state of emergency.--The term `declared
state of emergency' means an officially designated state of
emergency that has been declared by the Federal Government or
the head of the appropriate State or local governmental agency
having authority to declare that the State, county,
municipality, or locality is in a state of emergency, but does
not include a state of emergency that results from a labor
dispute in the health care industry or consistent
understaffing.
``(2) Participating hospital.--The term `participating
hospital' means a hospital (as defined in section 1861(e)) that
has entered into a provider agreement under section 1866.
``(3) Person.--The term `person' means one or more
individuals, associations, corporations, unincorporated
organizations, or labor unions.
``(4) Registered nurse.--The term `registered nurse' means
an individual who has been granted a license to practice as a
registered nurse in at least one State.
``(5) Shift.--The term `shift' means a scheduled set of
hours or duty period to be worked at a participating hospital.
``(6) Unit.--The term `unit' means, with respect to a
hospital, an organizational department or separate geographic
area of a hospital, including a burn unit, a labor and delivery
room, a post-anesthesia service area, an emergency department,
an operating room, a pediatric unit, a stepdown or intermediate
care unit, a specialty care unit, a telemetry unit, a general
medical care unit, a subacute care unit, and a transitional
inpatient care unit.''.
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