Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2021

I 117TH CONGRESS 1ST SESSION H. R. 3165 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 12, 2021 Ms. SCHAKOWSKY (for herself, Mr. RUSH, Mr. KHANNA, Mr. COHEN, Mr. TAKANO, Ms. MOORE of Wisconsin, Ms. LEE of California, Ms. VELA´ZQUEZ, Mr. BLUMENAUER, Mr. SHERMAN, Ms. JAYAPAL, and Ms. LOFGREN) introduced the following bill; which was referred to the Com- mittee 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 require- ments in hospitals, and for other purposes. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE; TABLE OF CONTENTS; FINDINGS. 3 (a) SHORT TITLE.—This Act may be cited as the 4 ‘‘Nurse Staffing Standards for Hospital Patient Safety 5 and Quality Care Act of 2021’’. 6 VerDate Sep 11 2014 03:20 Jun 12, 2021 Jkt 019200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H3165.IH H3165 kjohnson on DSK79L0C42PROD with BILLS 2 •HR 3165 IH (b) TABLE OF CONTENTS.—The table of contents for 1 this Act is as follows: 2 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: 3 (1) The Federal Government has a substantial 4 interest in promoting quality care and improving the 5 delivery of health care services to patients in health 6 care facilities in the United States. 7 (2) Recent changes in health care delivery sys- 8 tems that have resulted in higher acuity levels 9 among patients in health care facilities increase the 10 need for improved quality measures in order to pro- 11 tect patient care and reduce the incidence of medical 12 errors. 13 (3) Inadequate and poorly monitored registered 14 nurse staffing practices that result in too few reg- 15 istered nurses providing direct care jeopardize the 16 delivery of quality health care services. 17 (4) Numerous studies have shown that patient 18 outcomes are directly correlated to direct care reg- 19 istered nurse staffing levels, including a 2010 20 Health Services Research study that concluded that 21 implementation of minimum nurse-to-patient staff- 22 ing ratios in California has led to improved patient 23 VerDate Sep 11 2014 03:20 Jun 12, 2021 Jkt 019200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H3165.IH H3165 kjohnson on DSK79L0C42PROD with BILLS 3 •HR 3165 IH outcomes and nurse retention and a 2014 Agency 1 for Healthcare Research and Quality study that con- 2 cluded increases in nurse staffing and skill mix lead 3 to improved quality and reduced length of stay at no 4 additional cost. 5 (5) Requirements for direct care registered 6 nurse staffing ratios will help address the registered 7 nurse shortage in the United States by aiding in re- 8 cruitment of new registered nurses and improving 9 retention of registered nurses who are considering 10 leaving direct patient care because of demands cre- 11 ated by inadequate staffing. 12 (6) Establishing adequate minimum direct care 13 registered nurse-to-patient ratios that take into ac- 14 count patient acuity measures will improve the deliv- 15 ery of quality health care services and guarantee pa- 16 tient safety. 17 (7) Establishing safe staffing standards for di- 18 rect care registered nurses is a critical component of 19 assuring that there is adequate hospital staffing at 20 all levels to improve the delivery of quality care and 21 protect patient safety. 22 VerDate Sep 11 2014 03:20 Jun 12, 2021 Jkt 019200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H3165.IH H3165 kjohnson on DSK79L0C42PROD with BILLS 4 •HR 3165 IH SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE 1 STAFFING REQUIREMENT. 2 (a) MINIMUM DIRECT CARE REGISTERED NURSE 3 STAFFING REQUIREMENTS.—The Public Health Service 4 Act (42 U.S.C. 201 et seq.) is amended by adding at the 5 end the following new title: 6 ‘‘TITLE XXXIV—MINIMUM DI- 7 RECT CARE REGISTERED 8 NURSE STAFFING REQUIRE- 9 MENT 10 ‘‘SEC. 3401. MINIMUM NURSE STAFFING REQUIREMENT. 11 ‘‘(a) STAFFING PLAN.— 12 ‘‘(1) IN GENERAL.—A hospital shall implement 13 a staffing plan that— 14 ‘‘(A) provides adequate, appropriate, and 15 quality delivery of health care services and pro- 16 tects patient safety; and 17 ‘‘(B) is consistent with the requirements of 18 this title. 19 ‘‘(2) EFFECTIVE DATES.— 20 ‘‘(A) IMPLEMENTATION OF STAFFING 21 PLAN.—Subject to subparagraph (B), the re- 22 quirements under paragraph (1) shall take ef- 23 fect on a date to be determined by the Sec- 24 retary, but not later than 1 year after the date 25 of the enactment of this title. 26 VerDate Sep 11 2014 03:20 Jun 12, 2021 Jkt 019200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H3165.IH H3165 kjohnson on DSK79L0C42PROD with BILLS 5 •HR 3165 IH ‘‘(B) APPLICATION OF MINIMUM DIRECT 1 CARE REGISTERED NURSE-TO-PATIENT RA- 2 TIOS.—The requirements under subsection (b) 3 shall take effect as soon as practicable, as de- 4 termined by the Secretary, but not later than— 5 ‘‘(i) 2 years after the date of enact- 6 ment of this title; and 7 ‘‘(ii) in the case of a hospital in a 8 rural area (as defined in section 9 1886(d)(2)(D) of the Social Security Act), 10 4 years after the date of enactment of this 11 title. 12 ‘‘(b) MINIMUM DIRECT CARE REGISTERED NURSE- 13 TO-PATIENT RATIOS.— 14 ‘‘(1) IN GENERAL.—Except as provided in para- 15 graph (4) and other provisions of this section, a hos- 16 pital’s staffing plan shall provide that, at all times 17 during each shift within a unit of the hospital, and 18 with a full complement of ancillary and support 19 staff, a direct care registered nurse may be assigned 20 to not more than the following number of patients 21 in that unit: 22 ‘‘(A) One patient in trauma emergency 23 units. 24 VerDate Sep 11 2014 03:20 Jun 12, 2021 Jkt 019200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H3165.IH H3165 kjohnson on DSK79L0C42PROD with BILLS 6 •HR 3165 IH ‘‘(B) One patient in operating room units, 1 provided that a minimum of 1 additional person 2 serves as a scrub assistant in such unit. 3 ‘‘(C) Two patients in critical care units, in- 4 cluding neonatal intensive care units, emer- 5 gency critical care and intensive care units, 6 labor and delivery units, coronary care units, 7 acute respiratory care units, postanesthesia 8 units, and burn units. 9 ‘‘(D) Three patients in emergency room 10 units, pediatrics units, stepdown units, telem- 11 etry units, antepartum units, and combined 12 labor, deliver, and postpartum units. 13 ‘‘(E) Four patients in medical-surgical 14 units, intermediate care nursery units, acute 15 care psychiatric units, and other specialty care 16 units. 17 ‘‘(F) Five patients in rehabilitation units 18 and skilled nursing units. 19 ‘‘(G) Six patients in postpartum (3 cou- 20 plets) units and well-baby nursery units. 21 ‘‘(2) SIMILAR UNITS WITH DIFFERENT 22 NAMES.—The Secretary may apply minimum direct 23 care registered nurse-to-patient ratios established in 24 paragraph (1) for a hospital unit referred to in such 25 VerDate Sep 11 2014 03:20 Jun 12, 2021 Jkt 019200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H3165.IH H3165 kjohnson on DSK79L0C42PROD with BILLS 7 •HR 3165 IH paragraph to a type of hospital unit not referred to 1 in such paragraph if such type of hospital unit pro- 2 vides a level of care to patients whose needs are 3 similar to the needs of patients cared for in the hos- 4 pital unit referred to in such paragraph. 5 ‘‘(3) APPLICATION OF RATIOS TO HOSPITAL 6 NURSING PRACTICE STANDARDS.— 7 ‘‘(A) IN GENERAL.—A patient assignment 8 may be included in the calculation of the direct 9 care registered nurse-to-patient ratios required 10 in this subsection only if care is provided by a 11 direct care registered nurse and the provision of 12 care to the particular patient is within that di- 13 rect care registered nurse’s competence. 14 ‘‘(B) DEMONSTRATION OF UNIT-SPECIFIC 15 COMPETENCE.—A hospital shall not assign a di- 16 rect care registered nurse to a hospital unit un- 17 less that hospital determines that the direct 18 care registered nurse has demonstrated current 19 competence in providing care in that unit, and 20 has also received orientation to that hospital’s 21 unit sufficient to provide competent care to pa- 22 tients in that unit. 23 ‘‘(C) DUTIES OF THE ASSIGNED DIRECT 24 CARE REGISTERED NURSE.—Each patient shall 25 VerDate Sep 11 2014 03:20 Jun 12, 2021 Jkt 019200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H3165.IH H3165 kjohnson on DSK79L0C42PROD with BILLS 8 •HR 3165 IH be assigned to a direct care registered nurse 1 who shall directly provide the assessment, plan- 2 ning, supervision, implementation, and evalua- 3 tion of the nursing care provided to the patient 4 at least every shift and has the responsibility 5 for the provision of care to a particular patient 6 within his or her scope of practice. 7 ‘‘(D) NURSE ADMINISTRATORS AND SU- 8 PERVISORS.—A registered nurse who is a nurse 9 administrator, nurse supervisor, nurse manager, 10 charge nurse, case manager, or any other hos- 11 pital administrator or supervisor, shall not be 12 included in the calculation of the direct care 13 registered nurse-to-patient ratio unless that 14 nurse has a current and active direct patient 15 care assignment and provides direct patient 16 care in compliance with the requirements of this 17 section, including competency requirements. 18 The exemption in this subsection shall apply 19 only during the hours in which the individual 20 registered nurse has the principal responsibility 21 of providing direct patient care and has no ad- 22 ditional job duties as would a direct care reg- 23 istered nurse. 24 VerDate Sep 11 2014 03:20 Jun 12, 2021 Jkt 019200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H3165.IH H3165 kjohnson on DSK79L0C42PROD with BILLS 9 •HR 3165 IH ‘‘(E) OTHER PERSONNEL.—Other per- 1 sonnel may perform patient care tasks based on 2 their training and demonstrated skill but may 3 not perform or assist in direct care registered 4 nurse functions unless authorized to do in ac- 5 cordance with State scope of practice laws and 6 regulations. 7 ‘‘(F) TEMPORARY NURSING PERSONNEL.— 8 A hospital shall not assign any nursing per- 9 sonnel from temporary nursing agencies patient 10 care to any hospital unit without such personnel 11 having demonstrated competence on the as- 12 signed unit and received orientation to that hos- 13 pital’s unit sufficient to provide competent care 14 to patients in that unit. 15 ‘‘(G) ANCILLARY AND ADDITIONAL STAFF- 16 ING.—The need for additional staffing of direct 17 care registered nurses, licensed vocational or 18 practical nurses, licensed psychiatric techni- 19 cians, certified nursing or patient care assist- 20 ants, or other licensed or unlicensed ancillary 21 staff above the minimum registered nurse-to-pa- 22 tient ratios shall be based on the assessment of 23 the individual patient’s nursing care require- 24 VerDate Sep 11 2014 03:20 Jun 12, 2021 Jkt 019200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H3165.IH H3165 kjohnson on DSK79L0C42PROD with BILLS 10 •HR 3165 IH ment, the individual patient’s nursing care plan, 1 and acuity level. 2 ‘‘(4) RESTRICTIONS.— 3 ‘‘(A) PROHIBITION AGAINST AVERAGING.— 4 A hospital shall not average the number of pa- 5 tients and the total number of direct care reg- 6 istered nurses assigned to patients in a hospital 7 unit during any 1 shift or over any period of 8 time for purposes of meeting the requirements 9 under this subsection. 10 ‘‘(B) PROHIBITION AGAINST IMPOSITION 11 OF MANDATORY OVERTIME REQUIREMENTS.—A 12 hospital shall not impose mandatory overtime 13 requirements to meet the hospital unit direct 14 care registered nurse-to-patient ratios required 15 under this subsection. 16 ‘‘(C) RELIEF DURING ROUTINE AB- 17 SENCES.—A hospital shall ensure that only a 18 direct care registered nurse who has dem- 19 onstrated current competence to the hospital in 20 providing care on a particular unit and has also 21 received orientation to that hospital’s unit suffi- 22 cient to provide competent care to patients in 23 that unit may relieve another direct care reg- 24 VerDate Sep 11 2014 03:20 Jun 12, 2021 Jkt 019200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H3165.IH H3165 kjohnson on DSK79L0C42PROD with BILLS 11 •HR 3165 IH istered nurse during breaks, meals, and other 1 routine, expected absences from a hospital unit. 2 ‘‘(D) APPLICATION OF DIRECT CARE REG- 3 ISTERED NURSE-TO-PATIENT RATIOS IN PA- 4 TIENT-ACUITY ADJUSTABLE UNITS.—Patients 5 shall be cared for only on units or patient care 6 areas where the direct care registered nurse-to- 7 patient ratios meet the level of intensity, type 8 of care, and the individual requirements and 9 needs of each patient. Notwithstanding para- 10 graph (2), hospitals that provide patient care in 11 units or patient care areas that are acuity 12 adaptable or acuity adjustable shall apply the 13 direct care registered nurse-to-patient ratio re- 14 quired in this section for the highest patient 15 acuity level or level of care in that unit or pa- 16 tient care area, and shall comply with all other 17 requirements of this section. 18 ‘‘(E) USE OF VIDEO MONITORS.—A hos- 19 pital shall not employ video monitors or any 20 form of electronic visualization of a patient as 21 a substitute for the direct observation required 22 for patient assessment by the direct care reg- 23 istered nurse or required for patient protection. 24 Video monitors or any form of electronic visual- 25 VerDate Sep 11 2014 03:20 Jun 12, 2021 Jkt 019200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H3165.IH H3165 kjohnson on DSK79L0C42PROD with BILLS 12 •HR 3165 IH ization of a patient shall not be included in the 1 calculation of the direct care registered nurse- 2 to-patient ratio required in this subsection and 3 shall not replace the requirement of paragraph 4 (3)(D) that each patient shall be assigned to a 5 direct care registered nurse who shall directly 6 provide the assessment, planning, supervision, 7 implementation, and evaluation of the nursing 8 care provided to the patient at least every shift 9 and have the responsibility for the provision of 10 care to a particular patient within his [Text truncated for display. 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