What This Bill Does
This bill requires hospitals to establish and follow staffing plans with minimum numbers of direct care registered nurses assigned to patients. The bill sets specific nurse-to-patient ratios for different hospital units and creates requirements for hospitals to follow and report on their staffing levels.
##
Who It Affects
- Hospitals receiving Medicare or Medicaid payments
- Registered nurses working in hospitals
- Licensed practical nurses working in hospitals
- Hospital patients
- Veterans Affairs hospitals
- Department of Defense hospitals
- Indian Health Services hospitals
- Federal employee hospitals
##
Key Provisions
- Hospitals must implement staffing plans that provide minimum numbers of direct care registered nurses, with specific ratios for different hospital units like trauma, emergency rooms, critical care, and surgical units. (Sec. 3401(b))
- Hospitals cannot average nurse staffing numbers across shifts or over time, must not require mandatory overtime to meet ratios, and cannot use video monitors to substitute for direct nurse observation of patients. (Sec. 3401(b)(4))
- Hospitals must post notices showing actual nurse-to-patient ratios during each shift and maintain records for at least three years that document staffing levels and nurse assignments. (Sec. 3402)
- Nurses can refuse unsafe or inappropriate patient assignments without facing discharge, retaliation, or discrimination from hospitals. (Sec. 3405(c) and (d))
- The Secretary of Health and Human Services must establish a toll-free hotline for reporting staffing violations and must investigate complaints filed by nurses, patients, or other individuals. (Sec. 3405(g) and (f))
- Hospitals that violate staffing requirements face civil money penalties of up to $25,000 for the first violation and up to $50,000 for subsequent violations. (Sec. 3406(d))
##
What Changes
If this bill becomes law, hospitals will be required to maintain specific minimum numbers of registered nurses per patient in different hospital units. Hospitals must implement these staffing plans within one year and apply the specific patient ratios within two years (four years for rural hospitals). Hospitals must publicly post their actual staffing levels each shift. Nurses gain the right to refuse unsafe assignments without penalty. Hospitals must document and report staffing levels, and the federal government will enforce these requirements through Medicare and Medicaid program rules.
##
Important Definitions
- **Direct care registered nurse**: A person licensed by a state to practice as a registered nurse who provides bedside care to one or more patients
- **Direct care licensed practical nurse**: A person licensed by a state to practice as a licensed practical nurse or licensed vocational nurse who provides bedside care to one or more patients
- **Acuity level**: The determination of nursing care requirements based on the severity and complexity of a patient's illness, need for specialized equipment, and intensity of nursing interventions required
- **Competence/Competent**: Satisfactory application of a registered nurse's duties and responsibilities in providing nursing care to specific patient populations based on state nursing laws
- **State of emergency**: An unpredictable or unavoidable event requiring immediate medical interventions, but does not include emergencies caused by labor disputes or consistent understaffing
- **Staffing plan**: A plan required under the bill that provides adequate and appropriate delivery of health care services and protects patient safety
- **Nursing care plan**: A plan developed by the assigned registered nurse indicating the nursing care to be given to individual patients, considering acuity level and patient needs
##
Effective Date
Hospitals must implement their staffing plans within one year of the bill becoming law. Hospitals must apply the specific minimum nurse-to-patient ratios within two years of enactment, or within four years for hospitals in rural areas. Whistleblower protections begin when staffing requirements take effect in each hospital. Notices explaining nurse and patient rights must be posted within 18 months of enactment.
I
118TH CONGRESS
1ST SESSION H. R. 2530
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
APRIL 6, 2023
Ms. SCHAKOWSKY (for herself, Ms. JACOBS, Mr. DOGGETT, Mr. TAKANO, Ms.
MCCOLLUM, Mr. QUIGLEY, Mr. POCAN, Ms. CASTOR of Florida, Ms.
MENG, Mr. ESPAILLAT, Mr. HUFFMAN, Ms. VELA´ZQUEZ, Mr. SMITH of
Washington, Ms. PORTER, Ms. KELLY of Illinois, Mr. COHEN, Ms.
BONAMICI, Ms. MOORE of Wisconsin, Mr. BOWMAN, Ms. SEWELL, Mr.
KRISHNAMOORTHI, Ms. WILLIAMS
of Georgia, Ms. SA´NCHEZ, Ms.
JAYAPAL, Ms. SLOTKIN, Ms. NORTON, Ms. TLAIB, Mrs. DINGELL, Ms.
BARRAGA´N, Mr. GOMEZ, Mr. FOSTER, Mr. DELUZIO, Mr. GRIJALVA, Ms.
BUDZINSKI, Ms. CHU, Mr. RASKIN, Ms. BROWNLEY, Ms. LEE of Cali-
fornia, Mr. GARCI´A of Illinois, Mr. MULLIN, Mr. MCGOVERN, Mrs.
NAPOLITANO, Ms. BUSH, Mr. DAVIS of Illinois, Mr. SWALWELL, Ms.
OCASIO-CORTEZ, Mr. CASAR, Mr. KHANNA, Mr. NADLER, Ms. PRESSLEY,
Mrs. FOUSHEE, Mr. THANEDAR, Ms. TITUS, Mr. SOTO, Mr. CARTER of
Louisiana, and Mrs. HAYES) introduced the following bill; which was re-
ferred to the Committee on Energy and Commerce, and in addition to
the Committee on Ways and Means, for a period to be subsequently de-
termined 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.
VerDate Sep 11 2014
03:35 Apr 14, 2023
Jkt 039200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6652
E:\BILLS\H2530.IH
H2530
pbinns on DSKJLVW7X2PROD with $$_JOB
2
•HR 2530 IH
Be it enacted by the Senate and House of Representa-
1
tives of the United States of America in Congress assembled,
2
SECTION 1. SHORT TITLE; TABLE OF CONTENTS; FINDINGS.
3
(a) SHORT TITLE.—This Act may be cited as the
4
‘‘Nurse Staffing Standards for Hospital Patient Safety
5
and Quality Care Act of 2023’’.
6
(b) TABLE OF CONTENTS.—The table of contents for
7
this Act is as follows:
8
Sec. 1. Short title; table of contents; findings.
Sec. 2. Minimum direct care registered nurse staffing requirement.
Sec. 3. Enforcement of requirements through Federal programs.
Sec. 4. Nurse workforce initiative.
(c) FINDINGS.—Congress finds the following:
9
(1) The Federal Government has a substantial
10
interest in promoting quality care and improving the
11
delivery of health care services to patients in health
12
care facilities in the United States.
13
(2) Recent changes in health care delivery sys-
14
tems that have resulted in higher acuity levels
15
among patients in health care facilities increase the
16
need for improved quality measures in order to pro-
17
tect patient care and reduce the incidence of medical
18
errors.
19
(3) Inadequate and poorly monitored registered
20
nurse staffing practices that result in too few reg-
21
istered nurses providing direct care jeopardize the
22
delivery of quality health care services.
23
VerDate Sep 11 2014
03:35 Apr 14, 2023
Jkt 039200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6201
E:\BILLS\H2530.IH
H2530
pbinns on DSKJLVW7X2PROD with $$_JOB
3
•HR 2530 IH
(4) Numerous studies have shown that patient
1
outcomes are directly correlated to direct care reg-
2
istered nurse staffing levels, including a 2010
3
Health Services Research study that concluded that
4
implementation of minimum nurse-to-patient staff-
5
ing ratios in California has led to improved patient
6
outcomes and nurse retention and a 2014 Agency
7
for Healthcare Research and Quality study that con-
8
cluded increases in nurse staffing and skill mix lead
9
to improved quality and reduced length of stay at no
10
additional cost.
11
(5) Requirements for direct care registered
12
nurse staffing ratios will help address the registered
13
nurse shortage in the United States by aiding in re-
14
cruitment of new registered nurses and improving
15
retention of registered nurses who are considering
16
leaving direct patient care because of demands cre-
17
ated by inadequate staffing.
18
(6) Establishing adequate minimum direct care
19
registered nurse-to-patient ratios that take into ac-
20
count patient acuity measures will improve the deliv-
21
ery of quality health care services and guarantee pa-
22
tient safety.
23
(7) Establishing safe staffing standards for di-
24
rect care registered nurses is a critical component of
25
VerDate Sep 11 2014
03:35 Apr 14, 2023
Jkt 039200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6201
E:\BILLS\H2530.IH
H2530
pbinns on DSKJLVW7X2PROD with $$_JOB
4
•HR 2530 IH
assuring that there is adequate hospital staffing at
1
all levels to improve the delivery of quality care and
2
protect patient safety.
3
SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE
4
STAFFING REQUIREMENT.
5
(a) MINIMUM DIRECT CARE REGISTERED NURSE
6
STAFFING REQUIREMENTS.—The Public Health Service
7
Act (42 U.S.C. 201 et seq.) is amended by adding at the
8
end the following new title:
9
‘‘TITLE
XXXIV—MINIMUM
DI-
10
RECT
CARE
REGISTERED
11
NURSE STAFFING REQUIRE-
12
MENT
13
‘‘SEC. 3401. MINIMUM NURSE STAFFING REQUIREMENT.
14
‘‘(a) STAFFING PLAN.—
15
‘‘(1) IN GENERAL.—A hospital shall implement
16
a staffing plan that—
17
‘‘(A) provides adequate, appropriate, and
18
quality delivery of health care services and pro-
19
tects patient safety; and
20
‘‘(B) is consistent with the requirements of
21
this title.
22
‘‘(2) EFFECTIVE DATES.—
23
‘‘(A)
IMPLEMENTATION
OF
STAFFING
24
PLAN.—Subject to subparagraph (B), the re-
25
VerDate Sep 11 2014
03:35 Apr 14, 2023
Jkt 039200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\H2530.IH
H2530
pbinns on DSKJLVW7X2PROD with $$_JOB
5
•HR 2530 IH
quirements under paragraph (1) shall take ef-
1
fect on a date to be determined by the Sec-
2
retary, but not later than 1 year after the date
3
of the enactment of this title.
4
‘‘(B) APPLICATION
OF
MINIMUM
DIRECT
5
CARE
REGISTERED
NURSE-TO-PATIENT
RA-
6
TIOS.—The requirements under subsection (b)
7
shall take effect as soon as practicable, as de-
8
termined by the Secretary, but not later than—
9
‘‘(i) 2 years after the date of enact-
10
ment of this title; and
11
‘‘(ii) in the case of a hospital in a
12
rural
area
(as
defined
in
section
13
1886(d)(2)(D) of the Social Security Act),
14
4 years after the date of enactment of this
15
title.
16
‘‘(b) MINIMUM DIRECT CARE REGISTERED NURSE-
17
TO-PATIENT RATIOS.—
18
‘‘(1) IN GENERAL.—Except as provided in para-
19
graph (4) and other provisions of this section, a hos-
20
pital’s staffing plan shall provide that, at all times
21
during each shift within a unit of the hospital, and
22
with a full complement of ancillary and support
23
staff, a direct care registered nurse may be assigned
24
VerDate Sep 11 2014
03:35 Apr 14, 2023
Jkt 039200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H2530.IH
H2530
pbinns on DSKJLVW7X2PROD with $$_JOB
6
•HR 2530 IH
to not more than the following number of patients
1
in that unit:
2
‘‘(A) One patient in trauma emergency
3
units.
4
‘‘(B) One patient in operating room units,
5
provided that a minimum of 1 additional person
6
serves as a scrub assistant in such unit.
7
‘‘(C) Two patients in critical care units, in-
8
cluding neonatal intensive care units, emer-
9
gency critical care and intensive care units,
10
labor and delivery units, coronary care units,
11
acute respiratory care units, postanesthesia
12
units, and burn units.
13
‘‘(D) Three patients in emergency room
14
units, pediatrics units, stepdown units, telem-
15
etry units, antepartum units, and combined
16
labor, deliver, and postpartum units.
17
‘‘(E) Four patients in medical-surgical
18
units, intermediate care nursery units, acute
19
care psychiatric units, and other specialty care
20
units.
21
‘‘(F) Five patients in rehabilitation units
22
and skilled nursing units.
23
‘‘(G) Six patients in postpartum (3 cou-
24
plets) units and well-baby nursery units.
25
VerDate Sep 11 2014
03:35 Apr 14, 2023
Jkt 039200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H2530.IH
H2530
pbinns on DSKJLVW7X2PROD with $$_JOB
7
•HR 2530 IH
‘‘(2)
SIMILAR
UNITS
WITH
DIFFERENT
1
NAMES.—The Secretary may apply minimum direct
2
care registered nurse-to-patient ratios established in
3
paragraph (1) for a hospital unit referred to in such
4
paragraph to a type of hospital unit not referred to
5
in such paragraph if such type of hospital unit pro-
6
vides a level of care to patients whose needs are
7
similar to the needs of patients cared for in the hos-
8
pital unit referred to in such paragraph.
9
‘‘(3) APPLICATION
OF
RATIOS
TO
HOSPITAL
10
NURSING PRACTICE STANDARDS.—
11
‘‘(A) IN GENERAL.—A patient assignment
12
may be included in the calculation of the direct
13
care registered nurse-to-patient ratios required
14
in this subsection only if care is provided by a
15
direct care registered nurse and the provision of
16
care to the particular patient is within that di-
17
rect care registered nurse’s competence.
18
‘‘(B) DEMONSTRATION OF UNIT-SPECIFIC
19
COMPETENCE.—A hospital shall not assign a di-
20
rect care registered nurse to a hospital unit un-
21
less that hospital determines that the direct
22
care registered nurse has demonstrated current
23
competence in providing care in that unit, and
24
has also received orientation to that hospital’s
25
VerDate Sep 11 2014
03:35 Apr 14, 2023
Jkt 039200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H2530.IH
H2530
pbinns on DSKJLVW7X2PROD with $$_JOB
8
•HR 2530 IH
unit sufficient to provide competent care to pa-
1
tients in that unit.
2
‘‘(C) DUTIES OF THE ASSIGNED DIRECT
3
CARE REGISTERED NURSE.—Each patient shall
4
be assigned to a direct care registered nurse
5
who shall directly provide the assessment, plan-
6
ning, supervision, implementation, and evalua-
7
tion of the nursing care provided to the patient
8
at least every shift and has the responsibility
9
for the provision of care to a particular patient
10
within his or her scope of practice.
11
‘‘(D) NURSE
ADMINISTRATORS
AND
SU-
12
PERVISORS.—A registered nurse who is a nurse
13
administrator, nurse supervisor, nurse manager,
14
charge nurse, case manager, or any other hos-
15
pital administrator or supervisor, shall not be
16
included in the calculation of the direct care
17
registered nurse-to-patient ratio unless that
18
nurse has a current and active direct patient
19
care assignment and provides direct patient
20
care in compliance with the requirements of this
21
section, including competency requirements.
22
The exemption in this subsection shall apply
23
only during the hours in which the individual
24
registered nurse has the principal responsibility
25
VerDate Sep 11 2014
03:35 Apr 14, 2023
Jkt 039200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\H2530.IH
H2530
pbinns on DSKJLVW7X2PROD with $$_JOB
9
•HR 2530 IH
of providing direct patient care and has no ad-
1
ditional job duties as would a direct care reg-
2
istered nurse.
3
‘‘(E) OTHER
PERSONNEL.—Other per-
4
sonnel may perform patient care tasks based on
5
their training and demonstrated skill but may
6
not perform or assist in direct care registered
7
nurse functions unless authorized to do in ac-
8
cordance with State scope of practice laws and
9
regulations.
10
‘‘(F) TEMPORARY NURSING PERSONNEL.—
11
A hospital shall not assign any nursing per-
12
sonnel from temporary nursing agencies patient
13
care to any hospital unit without such personnel
14
having demonstrated competence on the as-
15
signed unit and received orientation to that hos-
16
pital’s unit sufficient to provide competent care
17
to patients in that unit.
18
‘‘(G) ANCILLARY AND ADDITIONAL STAFF-
19
ING.—The need for additional staffing of direct
20
care registered nurses, licensed vocational or
21
practical nurses, licensed psychiatric techni-
22
cians, certified nursing or patient care assist-
23
ants, or other licensed or unlicensed ancillary
24
staff above the minimum registered nurse-to-pa-
25
VerDate Sep 11 2014
03:35 Apr 14, 2023
Jkt 039200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H2530.IH
H2530
pbinns on DSKJLVW7X2PROD with $$_JOB
10
•HR 2530 IH
tient ratios shall be based on the assessment of
1
the individual patient’s nursing care require-
2
ment, the individual patient’s nursing care plan,
3
and acuity level.
4
‘‘(4) RESTRICTIONS.—
5
‘‘(A) PROHIBITION AGAINST AVERAGING.—
6
A hospital shall not average the number of pa-
7
tients and the total number of direct care reg-
8
istered nurses assigned to patients in a hospital
9
unit during any 1 shift or over any period of
10
time for purposes of meeting the requirements
11
under this subsection.
12
‘‘(B) PROHIBITION
AGAINST
IMPOSITION
13
OF MANDATORY OVERTIME REQUIREMENTS.—A
14
hospital shall not impose mandatory overtime
15
requirements to meet the hospital unit direct
16
care registered nurse-to-patient ratios required
17
under this subsection.
18
‘‘(C)
RELIEF
DURING
ROUTINE
AB-
19
SENCES.—A hospital shall ensure that only a
20
direct care registered nurse who has dem-
21
onstrated current competence to the hospital in
22
providing care on a particular unit and has also
23
received orientation to that hospital’s unit suffi-
24
cient to provide competent care to patients in
25
VerDate Sep 11 2014
03:35 Apr 14, 2023
Jkt 039200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H2530.IH
H2530
pbinns on DSKJLVW7X2PROD with $$_JOB
11
•HR 2530 IH
that unit may relieve another direct care reg-
1
istered nurse during breaks, meals, and other
2
routine, expected absences from a hospital unit.
3
‘‘(D) APPLICATION OF DIRECT CARE REG-
4
ISTERED
NURSE-TO-PATIENT
RATIOS
IN
PA-
5
TIENT-ACUITY
ADJUSTABLE
UNITS.—Patients
6
shall be cared for only on units or patient care
7
areas where the direct care registered nurse-to-
8
patient ratios meet the level of intensity, type
9
of care, and the individual requirements and
10
needs of each patient. Notwithstanding para-
11
graph (2), hospitals that provide patient care in
12
units or patient care areas that are acuity
13
adaptable or acuity adjustable shall apply the
14
direct care registered nurse-to-patient ratio re-
15
quired in this section for the highest patient
16
acuity level or level of care in that unit or pa-
17
tient care area, and shall comply with all other
18
requirements of this section.
19
‘‘(E) USE OF VIDEO MONITORS.—A hos-
20
pital shall not employ video monitors or any
21
form of electronic visualization of a patient as
22
a substitute for the direct observation required
23
for patient assessment by the direct care reg-
24
istered nurse or required for patient protection.
25
VerDate Sep 11 2014
03:35 Apr 14, 2023
Jkt 039200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6201
E:\BILLS\H2530.IH
H2530
[Text truncated for display. Full text available on Congress.gov.]