Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2019

I 116TH CONGRESS 1ST SESSION H. R. 2581 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 8, 2019 Ms. SCHAKOWSKY (for herself, Mr. DANNY K. DAVIS of Illinois, Mr. RASKIN, Mr. KHANNA, Mr. SHERMAN, Ms. NORTON, Ms. MCCOLLUM, Ms. BROWNLEY of California, Ms. LEE of California, Ms. WILSON of Florida, Mr. DEFAZIO, Ms. GABBARD, Ms. MOORE, Ms. DELAURO, Ms. CLARKE of New York, Ms. BONAMICI, Mr. TAKANO, Mr. BLUMENAUER, Mr. RUSH, Mr. POCAN, Ms. KELLY of Illinois, Mrs. DINGELL, Ms. LOFGREN, Ms. JAYAPAL, Ms. VELA´ZQUEZ, Mr. COHEN, and Mr. NADLER) intro- duced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend the Public Health Service Act to establish direct care registered nurse-to-patient staffing ratio 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 VerDate Sep 11 2014 05:26 May 14, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 \\ALPHA3\E\BILLS\H2581.IH H2581 kjohnson on DSK79L0C42 with BILLS 2 •HR 2581 IH SECTION 1. SHORT TITLE; TABLE OF CONTENTS; FINDINGS. 1 (a) SHORT TITLE.—This Act may be cited as the 2 ‘‘Nurse Staffing Standards for Hospital Patient Safety 3 and Quality Care Act of 2019’’. 4 (b) TABLE OF CONTENTS.—The table of contents for 5 this Act is as follows: 6 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: 7 (1) The Federal Government has a substantial 8 interest in promoting quality care and improving the 9 delivery of health care services to patients in health 10 care facilities in the United States. 11 (2) Recent changes in health care delivery sys- 12 tems that have resulted in higher acuity levels 13 among patients in health care facilities increase the 14 need for improved quality measures in order to pro- 15 tect patient care and reduce the incidence of medical 16 errors. 17 (3) Inadequate and poorly monitored registered 18 nurse staffing practices that result in too few reg- 19 istered nurses providing direct care jeopardize the 20 delivery of quality health care services. 21 (4) Numerous studies have shown that patient 22 outcomes are directly correlated to direct care reg- 23 VerDate Sep 11 2014 05:26 May 14, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 \\ALPHA3\E\BILLS\H2581.IH H2581 kjohnson on DSK79L0C42 with BILLS 3 •HR 2581 IH istered nurse staffing levels, including a 2010 1 Health Services Research study that concluded that 2 implementation of minimum nurse-to-patient staff- 3 ing ratios in California has led to improved patient 4 outcomes and nurse retention and a 2014 Agency 5 for Healthcare Research and Quality study that con- 6 cluded increases in nurse staffing and skill mix lead 7 to improved quality and reduced length of stay at no 8 additional cost. 9 (5) Requirements for direct care registered 10 nurse staffing ratios will help address the registered 11 nurse shortage in the United States by aiding in re- 12 cruitment of new registered nurses and improving 13 retention of registered nurses who are considering 14 leaving direct patient care because of demands cre- 15 ated by inadequate staffing. 16 (6) Establishing adequate minimum direct care 17 registered nurse-to-patient ratios that take into ac- 18 count patient acuity measures will improve the deliv- 19 ery of quality health care services and guarantee pa- 20 tient safety. 21 (7) Establishing safe staffing standards for di- 22 rect care registered nurses is a critical component of 23 assuring that there is adequate hospital staffing at 24 VerDate Sep 11 2014 05:26 May 14, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 \\ALPHA3\E\BILLS\H2581.IH H2581 kjohnson on DSK79L0C42 with BILLS 4 •HR 2581 IH all levels to improve the delivery of quality care and 1 protect patient safety. 2 SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE 3 STAFFING REQUIREMENT. 4 (a) MINIMUM DIRECT CARE REGISTERED NURSE 5 STAFFING REQUIREMENTS.—The Public Health Service 6 Act (42 U.S.C. 201 et seq.) is amended by adding at the 7 end the following new title: 8 ‘‘TITLE XXXIV—MINIMUM DI- 9 RECT CARE REGISTERED 10 NURSE STAFFING REQUIRE- 11 MENT 12 ‘‘SEC. 3401. MINIMUM NURSE STAFFING REQUIREMENT. 13 ‘‘(a) STAFFING PLAN.— 14 ‘‘(1) IN GENERAL.—A hospital shall implement 15 a staffing plan that— 16 ‘‘(A) provides adequate, appropriate, and 17 quality delivery of health care services and pro- 18 tects patient safety; and 19 ‘‘(B) is consistent with the requirements of 20 this title. 21 ‘‘(2) EFFECTIVE DATES.— 22 ‘‘(A) IMPLEMENTATION OF STAFFING 23 PLAN.—Subject to subparagraph (B), the re- 24 quirements under paragraph (1) shall take ef- 25 VerDate Sep 11 2014 05:26 May 14, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 \\ALPHA3\E\BILLS\H2581.IH H2581 kjohnson on DSK79L0C42 with BILLS 5 •HR 2581 IH fect on a date to be determined by the Sec- 1 retary, but not later than 1 year after the date 2 of the enactment of this title. 3 ‘‘(B) APPLICATION OF MINIMUM DIRECT 4 CARE REGISTERED NURSE-TO-PATIENT RA- 5 TIOS.—The requirements under subsection (b) 6 shall take effect as soon as practicable, as de- 7 termined by the Secretary, but not later than— 8 ‘‘(i) 2 years after the date of enact- 9 ment of this title; and 10 ‘‘(ii) in the case of a hospital in a 11 rural area (as defined in section 12 1886(d)(2)(D) of the Social Security Act), 13 4 years after the date of enactment of this 14 title. 15 ‘‘(b) MINIMUM DIRECT CARE REGISTERED NURSE- 16 TO-PATIENT RATIOS.— 17 ‘‘(1) IN GENERAL.—Except as provided in para- 18 graph (4) and other provisions of this section, a hos- 19 pital’s staffing plan shall provide that, at all times 20 during each shift within a unit of the hospital, and 21 with a full complement of ancillary and support 22 staff, a direct care registered nurse may be assigned 23 to not more than the following number of patients 24 in that unit: 25 VerDate Sep 11 2014 05:26 May 14, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 \\ALPHA3\E\BILLS\H2581.IH H2581 kjohnson on DSK79L0C42 with BILLS 6 •HR 2581 IH ‘‘(A) One patient in trauma emergency 1 units. 2 ‘‘(B) One patient in operating room units, 3 provided that a minimum of 1 additional person 4 serves as a scrub assistant in such unit. 5 ‘‘(C) Two patients in critical care units, in- 6 cluding neonatal intensive care units, emer- 7 gency critical care and intensive care units, 8 labor and delivery units, coronary care units, 9 acute respiratory care units, postanesthesia 10 units, and burn units. 11 ‘‘(D) Three patients in emergency room 12 units, pediatrics units, stepdown units, telem- 13 etry units, antepartum units, and combined 14 labor, deliver, and postpartum units. 15 ‘‘(E) Four patients in medical-surgical 16 units, intermediate care nursery units, acute 17 care psychiatric units, and other specialty care 18 units. 19 ‘‘(F) Five patients in rehabilitation units 20 and skilled nursing units. 21 ‘‘(G) Six patients in postpartum (3 cou- 22 plets) units and well-baby nursery units. 23 ‘‘(2) SIMILAR UNITS WITH DIFFERENT 24 NAMES.—The Secretary may apply minimum direct 25 VerDate Sep 11 2014 05:26 May 14, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 \\ALPHA3\E\BILLS\H2581.IH H2581 kjohnson on DSK79L0C42 with BILLS 7 •HR 2581 IH care registered nurse-to-patient ratios established in 1 paragraph (1) for a hospital unit referred to in such 2 paragraph to a type of hospital unit not referred to 3 in such paragraph if such type of hospital unit pro- 4 vides a level of care to patients whose needs are 5 similar to the needs of patients cared for in the hos- 6 pital unit referred to in such paragraph. 7 ‘‘(3) APPLICATION OF RATIOS TO HOSPITAL 8 NURSING PRACTICE STANDARDS.— 9 ‘‘(A) IN GENERAL.—A patient assignment 10 may be included in the calculation of the direct 11 care registered nurse-to-patient ratios required 12 in this subsection only if care is provided by a 13 direct care registered nurse and the provision of 14 care to the particular patient is within that di- 15 rect care registered nurse’s competence. 16 ‘‘(B) DEMONSTRATION OF UNIT-SPECIFIC 17 COMPETENCE.—A hospital shall not assign a di- 18 rect care registered nurse to a hospital unit un- 19 less that hospital determines that the direct 20 care registered nurse has demonstrated current 21 competence in providing care in that unit, and 22 has also received orientation to that hospital’s 23 unit sufficient to provide competent care to pa- 24 tients in that unit. 25 VerDate Sep 11 2014 05:26 May 14, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 \\ALPHA3\E\BILLS\H2581.IH H2581 kjohnson on DSK79L0C42 with BILLS 8 •HR 2581 IH ‘‘(C) DUTIES OF THE ASSIGNED DIRECT 1 CARE REGISTERED NURSE.—Each patient shall 2 be assigned to a direct care registered nurse 3 who shall directly provide the assessment, plan- 4 ning, supervision, implementation, and evalua- 5 tion of the nursing care provided to the patient 6 at least every shift and has the responsibility 7 for the provision of care to a particular patient 8 within his or her scope of practice. 9 ‘‘(D) NURSE ADMINISTRATORS AND SU- 10 PERVISORS.—A registered nurse who is a nurse 11 administrator, nurse supervisor, nurse manager, 12 charge nurse, case manager, or any other hos- 13 pital administrator or supervisor, shall not be 14 included in the calculation of the direct care 15 registered nurse-to-patient ratio unless that 16 nurse has a current and active direct patient 17 care assignment and provides direct patient 18 care in compliance with the requirements of this 19 section, including competency requirements. 20 The exemption in this subsection shall apply 21 only during the hours in which the individual 22 registered nurse has the principal responsibility 23 of providing direct patient care and has no ad- 24 VerDate Sep 11 2014 05:26 May 14, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 \\ALPHA3\E\BILLS\H2581.IH H2581 kjohnson on DSK79L0C42 with BILLS 9 •HR 2581 IH ditional job duties as would a direct care reg- 1 istered nurse. 2 ‘‘(E) OTHER PERSONNEL.—Other per- 3 sonnel may perform patient care tasks based on 4 their training and demonstrated skill but may 5 not perform or assist in direct care registered 6 nurse functions unless authorized to do in ac- 7 cordance with State scope of practice laws and 8 regulations. 9 ‘‘(F) TEMPORARY NURSING PERSONNEL.— 10 A hospital shall not assign any nursing per- 11 sonnel from temporary nursing agencies patient 12 care to any hospital unit without such personnel 13 having demonstrated competence on the as- 14 signed unit and received orientation to that hos- 15 pital’s unit sufficient to provide competent care 16 to patients in that unit. 17 ‘‘(G) ANCILLARY AND ADDITIONAL STAFF- 18 ING.—The need for additional staffing of direct 19 care registered nurses, licensed vocational or 20 practical nurses, licensed psychiatric techni- 21 cians, certified nursing or patient care assist- 22 ants, or other licensed or unlicensed ancillary 23 staff above the minimum registered nurse-to-pa- 24 tient ratios shall be based on the assessment of 25 VerDate Sep 11 2014 05:26 May 14, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 \\ALPHA3\E\BILLS\H2581.IH H2581 kjohnson on DSK79L0C42 with BILLS 10 •HR 2581 IH the individual patient’s nursing care require- 1 ment, the individual patient’s nursing care plan, 2 and acuity level. 3 ‘‘(4) RESTRICTIONS.— 4 ‘‘(A) PROHIBITION AGAINST AVERAGING.— 5 A hospital shall not average the number of pa- 6 tients and the total number of direct care reg- 7 istered nurses assigned to patients in a hospital 8 unit during any 1 shift or over any period of 9 time for purposes of meeting the requirements 10 under this subsection. 11 ‘‘(B) PROHIBITION AGAINST IMPOSITION 12 OF MANDATORY OVERTIME REQUIREMENTS.—A 13 hospital shall not impose mandatory overtime 14 requirements to meet the hospital unit direct 15 care registered nurse-to-patient ratios required 16 under this subsection. 17 ‘‘(C) RELIEF DURING ROUTINE AB- 18 SENCES.—A hospital shall ensure that only a 19 direct care registered nurse who has dem- 20 onstrated current competence to the hospital in 21 providing care on a particular unit and has also 22 received orientation to that hospital’s unit suffi- 23 cient to provide competent care to patients in 24 that unit may relieve another direct care reg- 25 VerDate Sep 11 2014 05:26 May 14, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 \\ALPHA3\E\BILLS\H2581.IH H2581 kjohnson on DSK79L0C42 with BILLS 11 •HR 2581 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 05:26 May 14, 2019 Jkt 089200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 \\ALPHA3\E\BILLS\H2581.IH H2581 kjohnson on DSK79L0C42 with BILLS 12 •HR 2581 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 [Text truncated for display. 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