Nurse Staffing Standards for Patient Safety and Quality Care Act of 2021
This bill requires hospitals to implement and submit to the Department of Health and Human Services (HHS) a staffing plan that complies with specified minimum nurse-to-patient ratios by unit. Hospitals must post a notice regarding nurse-to-patient ratios in each unit and maintain records of actual ratios for each shift in each unit. The bill also requires hospitals to follow certain procedures regarding how ratios are determined and other staff are prohibited from performing nurse functions unless specifically authorized within a state's scope of practice rules, among other requirements.
HHS must adjust Medicare payments to hospitals to cover additional costs attributable to compliance with these ratios.
Nurses may object to, or refuse to participate in, an assignment if it would violate minimum ratios or if they are not prepared by education or experience to fulfill the assignment without compromising the safety of a patient or jeopardizing their nurse's license. Hospitals may not (1) take adverse actions against a nurse based on the nurse's reasonable refusal to accept an assignment; or (2) discriminate against individuals for good faith complaints relating to the care, services, or conditions of the hospital or related facilities. HHS may impose civil monetary penalties on hospitals violating the ratio requirements and must publish the names of such hospitals.
The bill provides stipends to the nurse workforce loan repayment and scholarship program and expands the nurse retention grant program to include nurse preceptorship and mentorship projects.
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 2021''.
    (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 (85);
            (2) by striking the period at the end of paragraph (86) and 
        inserting ``; and''; and
            (3) by inserting after paragraph (86) the following new 
        paragraph:
            ``(87) 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 title,'' and inserting ``Subject to 
        subsections (b) and (c),''.

SEC. 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 program for registered 
        nurses; or
            ``(5) to implement mentorship projects that assist new or 
        transitional direct care registered nurses in adapting to the 
        hospital setting.''.
                                 <all>
Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2021
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.
Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2021
Sen. Brown, Sherrod