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1396a ) is amended by adding at the end the following: The Secretary may, by regulation, promulgate standards or methodologies for determining rates that comply with paragraph (13), and a State that pays rates that meet such standards or methodologies is deemed to be in compliance with paragraph (13).. (c) Effective date
The amendments made by this section shall apply to services furnished on or after the date that is one year after the date of the enactment of this Act. 6. Increase of Medicaid FMAP
Section 1905(b) of the Social Security Act ( 42 U.S.C.
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1396d(b) ) is amended by adding at the end the following: Notwithstanding the first sentence of this subsection, only for purposes of this title (and not with respect to the determination of the enhanced FMAP) and with respect to calendar quarters beginning after October 1, 2004, in the case of a State in which the Federal medical assistance percentage otherwise determined under the first sentence is less than 60 percent, such percentage shall be increased by 2 percentage points, and in the case of a State in which such percentage is otherwise so determined to be 60 percent or greater,
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such percentage shall be increased by 1 percentage point.
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1. Short Title; Findings
(a) Short title
This Act may be cited as the Nurse Staffing Standards for Patient Safety and Quality Care Act of 2004. (b) 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.
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(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 2002 Joint Commission on Accreditation of Healthcare Organizations report that concluded that the lack of direct care registered nurses contributed to nearly a quarter of the unanticipated problems that result in injury or death to hospital patients.
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(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.
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(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. 2. Minimum direct care registered nurse staffing requirement
(a) Minimum direct care registered nurse staffing requirement
The Public Health Service Act ( 42 U.S.C. 201 et seq. ) is amended by adding at the end the following new title: XXIX Minimum direct care registered nurse staffing requirement
2901.
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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 not later than 1 year after the date of the enactment of this title.
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(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 2 years after the date of the enactment of this title, or in the case of a hospital in a rural area (as defined in section 1886(d)(2)(B) of the Social Security Act ( 42 U.S.C. 1395ww(d)(2)(B) ), not later than 4 years after the date of the enactment of this title.
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(b) Minimum direct care registered nurse-to-patient ratios
(1) In general
A hospital’s staffing plan shall provide that, during each shift within a unit of the hospital, a direct care registered nurse may be assigned to not more than the following number of patients in that unit, subject to paragraph (3): (A) 1 patient in operating room units and trauma emergency units. (B) 2 patients in critical care units, including emergency critical care and intensive care units, labor and delivery units, and postanesthesia units.
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(C) 3 patients in antepartum units, emergency room units, pediatrics units, stepdown units, and telemetry units. (D) 4 patients in intermediate care nursery units, medical/surgical units, and acute care psychiatric units. (E) 5 patients in rehabilitation units. (F) 6 patients in postpartum (3 couplets) units and well-baby nursery units.
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(2) Similar units with different names
The Secretary may apply minimum direct care registered nurse-to-patient ratios established in paragraph (1) to a type of hospital unit not referred to in such paragraph if such other unit performs a function similar to the function performed by the unit referred to in such paragraph.
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(3) 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 further limit 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.
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(4) Relationship to State-imposed ratios
(A) No preemption of certain State-imposed ratios
Nothing in this title shall preempt State standards that the Secretary determines to be at least equivalent to 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 at least equivalent to Federal requirements for a staffing plan established under this title.
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(B) Satisfaction of certain Federal requirements with certain State-imposed nurse-to-patient ratios
States that, at least 2 years prior to the date of the enactment of this title, have enacted minimum direct care nurse-to-patient ratios that allow the use of licensed practical nurses to meet State-imposed minimum direct care nurse-to-patient ratios may continue to make such allowance, and such allowance shall be considered to satisfy requirements imposed under this subsection, so long as the particular licensed practical nurse is employed in the same or a comparable position.
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(5) Exemption in emergencies
(A) In general
The requirements established under this subsection shall not apply during a declared state of emergency if a hospital is requested or expected to provide an exceptional level of emergency or other medical services.
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(B) Emergency defined
For purposes of subparagraph (A), the term declared state of emergency means a state of emergency that has been declared by the Federal Government or the head of the appropriate State or local governmental agency having authority to declare that the State, county, municipality, or locality is in a state of emergency, but such term does not include a state of emergency that results from a labor dispute in the health care industry or consistent understaffing.
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(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 the following factors: (A) The number of patients and acuity level of patients as determined by the application of an acuity system (as defined in section 2906(1)), on a shift-by-shift basis.
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(B) The anticipated admissions, discharges, and transfers of patients during each shift that impacts direct patient care. (C) Specialized experience required of direct care registered nurses on a particular unit. (D) Staffing levels and services provided by other health care personnel in meeting direct patient care needs not required by a direct care registered nurse. (E) The level of technology available that affects the delivery of direct patient care. (F) The level of familiarity with hospital practices, policies, and procedures by temporary agency direct care registered nurses used during a shift.
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(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 and acuity system
(A) In general
A hospital shall annually evaluate— (i) its staffing plan in each unit in relation to actual patient care requirements; and (ii) the accuracy of its acuity system. (B) Update
A hospital shall update its staffing plan and acuity system to the extent appropriate based on such evaluation.
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(4) Registered nurse participation
A staffing plan of a hospital 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 or, where such nurses are represented through collective bargaining, from 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 or under the Federal Labor Relations Act. (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).
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A federally operated hospital may submit its staffing plan through the department or agency operating the hospital. 2902. 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 2901; (2) includes actual direct care registered nurse-to-patient ratios during each shift; and (3) is visible, conspicuous, and accessible to staff, patients, and the public.
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(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 each direct care registered nurse assigned to each patient in each unit in each shift; and (C) a copy of each notice posted under subsection (a).
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(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 ).
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(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. 2903. 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).
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(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.
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(c) Application of registered nurse provisions to licensed practical nurse staffing requirements
Paragraphs (2), (3), (4)(A), and (5) of section 2901(b), section 2901(c), and section 2902 shall apply to the establishment and application of direct care licensed practical nurse staffing requirements under this section in the same manner that they apply to the establishment and application of direct care registered nurse-to-patient ratios under section 2901.
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(d) Effective date
The requirements of this section shall take effect as soon as practicable, as determined by the Secretary, but not later than 2 years after the date of the enactment of this title, or in the case of a hospital in a rural area (as defined in section 1886(d)(2)(B) of the Social Security Act ( 42 U.S.C. 1395ww(d)(2)(B) ), not later than 4 years after the date of the enactment of this title. 2904.
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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 2901 through 2903. 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).
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(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 2901 through 2903. (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 ( 42 U.S.C.
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1395b-6 )) shall submit to Congress and the Secretary a report estimating total costs and savings attributable to compliance with requirements imposed under sections 2901 through 2903. Such report shall include recommendations on the need, if any, to adjust reimbursement for Medicare payments under subsection (a). 2905.
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Protection of nurses and other individuals
(a) Refusal of assignment
A nurse may refuse to accept an assignment as a nurse in a hospital if— (1) the assignment would violate section 2901 or 2903; 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.
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(b) Retaliation for refusal of assignment barred
(1) No discharge, discrimination, or retaliation
No hospital shall discharge, discriminate, or retaliate in any manner with respect to any aspect of employment (as defined in section 2906(5)), including discharge, promotion, compensation, or terms, conditions, or privileges of employment against a nurse based on the nurse’s refusal of a work assignment under subsection (a).
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(2) No filing of complaint
No hospital shall file a complaint or a report against a nurse with the appropriate State professional disciplinary agency because of the nurse’s refusal of a work assignment under subsection (a). (c) Cause of action
Any nurse who has been discharged, discriminated, or retaliated against in violation of subsection (b)(1) or against whom a complaint has been filed in violation of subsection (b)(2) may bring a cause of action in a United States district court.
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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. (d) Complaint to Secretary
A nurse or other individual may file a complaint with the Secretary against a hospital that violates the provisions of this title.
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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 retaliation under subsection (b) or under subsection (e). (e) Protection for reporting
(1) Retaliation barred
A hospital shall not discriminate or retaliate in any manner with respect to any aspect of employment, including hiring, discharge, promotion, compensation, or terms, conditions,
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or privileges of employment against any individual who in good faith, individually or in conjunction with another person or persons— (A) reports a violation or a suspected violation of this title to the Secretary, a public regulatory agency, a private accreditation body, or the management personnel of the hospital; (B) initiates, cooperates, or otherwise participates in an investigation or proceeding brought by the Secretary, a public regulatory agency, or a private accreditation body concerning matters covered by this title; or (C) informs or discusses with other individuals or with representatives of hospital employees a violation or suspected violation of this title.
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(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.
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(f) 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 and other individuals under this section; (2) includes a statement that a nurse 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 a complaint under paragraph (2).
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(g) Effective dates
(1) Refusal; retaliation; cause of action
(A) In general
Subsections (a) through (c) shall apply to refusals occurring on or after the effective date of the provision to which the refusal relates. (B) Exception
Subsection (a)(2) shall not apply to refusals in any hospital before the requirements of section 2901(a) apply to that hospital.
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(2) Protections for reporting
Subsection (e) shall apply to actions described in subparagraphs (A) and (C) of subsection (e)(1) occurring on or after the effective date of the provision to which the violation relates. Subsection (e) shall apply to initiation, cooperation, or participation in an investigation or proceeding on or after the date of the enactment of this title. (3) Notice
Subsection (f) shall take effect 18 months after the date of the enactment of this title. 2906.
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Definitions
For purposes of this title: (1) Acuity system
The term acuity system means an established measurement tool that— (A) predicts nursing care requirements for individual patients based on severity of patient illness, need for specialized equipment and technology, intensity of nursing interventions required, and the complexity of clinical nursing judgment needed to design, implement, and evaluate the patient’s nursing care plan; (B) details the amount of nursing care needed, both in number of nurses and in skill mix of nursing personnel required, on a daily basis, for each patient in a nursing department or unit;
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(C) takes into consideration the patient care services provided not only by registered nurses but also by direct care licensed practical nurses and other health care personnel; and (D) is stated in terms that can be readily used and understood by nurses. (2) Direct care licensed practical nurse
The term direct care licensed practical nurse means an individual who has been granted a license by at least 1 State to practice as a licensed practical nurse or a licensed vocational nurse and who provides bedside care for 1 or more patients.
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(3) Nurse
The term nurse means any direct care registered nurse or direct care licensed practical nurse (as the case may be), regardless of whether or not the nurse is an employee. (4) Direct care registered nurse
The term direct care registered nurse means an individual who has been granted a license by at least 1 State to practice as a registered nurse and who provides bedside care for 1 or more patients. (5) Employment
The term employment includes the provision of services under a contract or other arrangement.
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(6) Hospital
The term hospital has the meaning given that term in section 1861(e) of the Social Security Act ( 42 U.S.C. 1395x(e) ), 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.
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(7) Staffing plan
The term staffing plan means a staffing plan required under section 2901.. (b) Recommendations to Congress
No later than 1 year after the date of the 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 XXIX of the Public Health Service Act, as added by subsection (a). 2901.
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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 not later than 1 year after the date of the enactment of this title.
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(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 2 years after the date of the enactment of this title, or in the case of a hospital in a rural area (as defined in section 1886(d)(2)(B) of the Social Security Act ( 42 U.S.C. 1395ww(d)(2)(B) ), not later than 4 years after the date of the enactment of this title.
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(b) Minimum direct care registered nurse-to-patient ratios
(1) In general
A hospital’s staffing plan shall provide that, during each shift within a unit of the hospital, a direct care registered nurse may be assigned to not more than the following number of patients in that unit, subject to paragraph (3): (A) 1 patient in operating room units and trauma emergency units. (B) 2 patients in critical care units, including emergency critical care and intensive care units, labor and delivery units, and postanesthesia units.
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(C) 3 patients in antepartum units, emergency room units, pediatrics units, stepdown units, and telemetry units. (D) 4 patients in intermediate care nursery units, medical/surgical units, and acute care psychiatric units. (E) 5 patients in rehabilitation units. (F) 6 patients in postpartum (3 couplets) units and well-baby nursery units.
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(2) Similar units with different names
The Secretary may apply minimum direct care registered nurse-to-patient ratios established in paragraph (1) to a type of hospital unit not referred to in such paragraph if such other unit performs a function similar to the function performed by the unit referred to in such paragraph.
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(3) 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 further limit 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.
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(4) Relationship to State-imposed ratios
(A) No preemption of certain State-imposed ratios
Nothing in this title shall preempt State standards that the Secretary determines to be at least equivalent to 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 at least equivalent to Federal requirements for a staffing plan established under this title.
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(B) Satisfaction of certain Federal requirements with certain State-imposed nurse-to-patient ratios
States that, at least 2 years prior to the date of the enactment of this title, have enacted minimum direct care nurse-to-patient ratios that allow the use of licensed practical nurses to meet State-imposed minimum direct care nurse-to-patient ratios may continue to make such allowance, and such allowance shall be considered to satisfy requirements imposed under this subsection, so long as the particular licensed practical nurse is employed in the same or a comparable position.
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(5) Exemption in emergencies
(A) In general
The requirements established under this subsection shall not apply during a declared state of emergency if a hospital is requested or expected to provide an exceptional level of emergency or other medical services.
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(B) Emergency defined
For purposes of subparagraph (A), the term declared state of emergency means a state of emergency that has been declared by the Federal Government or the head of the appropriate State or local governmental agency having authority to declare that the State, county, municipality, or locality is in a state of emergency, but such term does not include a state of emergency that results from a labor dispute in the health care industry or consistent understaffing.
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(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 the following factors: (A) The number of patients and acuity level of patients as determined by the application of an acuity system (as defined in section 2906(1)), on a shift-by-shift basis.
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(B) The anticipated admissions, discharges, and transfers of patients during each shift that impacts direct patient care. (C) Specialized experience required of direct care registered nurses on a particular unit. (D) Staffing levels and services provided by other health care personnel in meeting direct patient care needs not required by a direct care registered nurse. (E) The level of technology available that affects the delivery of direct patient care. (F) The level of familiarity with hospital practices, policies, and procedures by temporary agency direct care registered nurses used during a shift.
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(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 and acuity system
(A) In general
A hospital shall annually evaluate— (i) its staffing plan in each unit in relation to actual patient care requirements; and (ii) the accuracy of its acuity system. (B) Update
A hospital shall update its staffing plan and acuity system to the extent appropriate based on such evaluation.
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(4) Registered nurse participation
A staffing plan of a hospital 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 or, where such nurses are represented through collective bargaining, from 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 or under the Federal Labor Relations Act. (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).
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A federally operated hospital may submit its staffing plan through the department or agency operating the hospital. 2902. 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 2901; (2) includes actual direct care registered nurse-to-patient ratios during each shift; and (3) is visible, conspicuous, and accessible to staff, patients, and the public.
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(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 each direct care registered nurse assigned to each patient in each unit in each shift; and (C) a copy of each notice posted under subsection (a).
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(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 ).
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(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. 2903. 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).
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(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.
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(c) Application of registered nurse provisions to licensed practical nurse staffing requirements
Paragraphs (2), (3), (4)(A), and (5) of section 2901(b), section 2901(c), and section 2902 shall apply to the establishment and application of direct care licensed practical nurse staffing requirements under this section in the same manner that they apply to the establishment and application of direct care registered nurse-to-patient ratios under section 2901.
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(d) Effective date
The requirements of this section shall take effect as soon as practicable, as determined by the Secretary, but not later than 2 years after the date of the enactment of this title, or in the case of a hospital in a rural area (as defined in section 1886(d)(2)(B) of the Social Security Act ( 42 U.S.C. 1395ww(d)(2)(B) ), not later than 4 years after the date of the enactment of this title. 2904.
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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 2901 through 2903. 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).
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(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 2901 through 2903. (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 ( 42 U.S.C.
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1395b-6 )) shall submit to Congress and the Secretary a report estimating total costs and savings attributable to compliance with requirements imposed under sections 2901 through 2903. Such report shall include recommendations on the need, if any, to adjust reimbursement for Medicare payments under subsection (a). 2905.
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Protection of nurses and other individuals
(a) Refusal of assignment
A nurse may refuse to accept an assignment as a nurse in a hospital if— (1) the assignment would violate section 2901 or 2903; 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.
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(b) Retaliation for refusal of assignment barred
(1) No discharge, discrimination, or retaliation
No hospital shall discharge, discriminate, or retaliate in any manner with respect to any aspect of employment (as defined in section 2906(5)), including discharge, promotion, compensation, or terms, conditions, or privileges of employment against a nurse based on the nurse’s refusal of a work assignment under subsection (a).
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(2) No filing of complaint
No hospital shall file a complaint or a report against a nurse with the appropriate State professional disciplinary agency because of the nurse’s refusal of a work assignment under subsection (a). (c) Cause of action
Any nurse who has been discharged, discriminated, or retaliated against in violation of subsection (b)(1) or against whom a complaint has been filed in violation of subsection (b)(2) may bring a cause of action in a United States district court.
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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. (d) Complaint to Secretary
A nurse or other individual may file a complaint with the Secretary against a hospital that violates the provisions of this title.
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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 retaliation under subsection (b) or under subsection (e). (e) Protection for reporting
(1) Retaliation barred
A hospital shall not discriminate or retaliate in any manner with respect to any aspect of employment, including hiring, discharge, promotion, compensation, or terms, conditions,
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or privileges of employment against any individual who in good faith, individually or in conjunction with another person or persons— (A) reports a violation or a suspected violation of this title to the Secretary, a public regulatory agency, a private accreditation body, or the management personnel of the hospital; (B) initiates, cooperates, or otherwise participates in an investigation or proceeding brought by the Secretary, a public regulatory agency, or a private accreditation body concerning matters covered by this title; or (C) informs or discusses with other individuals or with representatives of hospital employees a violation or suspected violation of this title.
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(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.
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(f) 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 and other individuals under this section; (2) includes a statement that a nurse 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 a complaint under paragraph (2).
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(g) Effective dates
(1) Refusal; retaliation; cause of action
(A) In general
Subsections (a) through (c) shall apply to refusals occurring on or after the effective date of the provision to which the refusal relates. (B) Exception
Subsection (a)(2) shall not apply to refusals in any hospital before the requirements of section 2901(a) apply to that hospital.
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(2) Protections for reporting
Subsection (e) shall apply to actions described in subparagraphs (A) and (C) of subsection (e)(1) occurring on or after the effective date of the provision to which the violation relates. Subsection (e) shall apply to initiation, cooperation, or participation in an investigation or proceeding on or after the date of the enactment of this title. (3) Notice
Subsection (f) shall take effect 18 months after the date of the enactment of this title. 2906.
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Definitions
For purposes of this title: (1) Acuity system
The term acuity system means an established measurement tool that— (A) predicts nursing care requirements for individual patients based on severity of patient illness, need for specialized equipment and technology, intensity of nursing interventions required, and the complexity of clinical nursing judgment needed to design, implement, and evaluate the patient’s nursing care plan; (B) details the amount of nursing care needed, both in number of nurses and in skill mix of nursing personnel required, on a daily basis, for each patient in a nursing department or unit;
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(C) takes into consideration the patient care services provided not only by registered nurses but also by direct care licensed practical nurses and other health care personnel; and (D) is stated in terms that can be readily used and understood by nurses. (2) Direct care licensed practical nurse
The term direct care licensed practical nurse means an individual who has been granted a license by at least 1 State to practice as a licensed practical nurse or a licensed vocational nurse and who provides bedside care for 1 or more patients.
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(3) Nurse
The term nurse means any direct care registered nurse or direct care licensed practical nurse (as the case may be), regardless of whether or not the nurse is an employee. (4) Direct care registered nurse
The term direct care registered nurse means an individual who has been granted a license by at least 1 State to practice as a registered nurse and who provides bedside care for 1 or more patients. (5) Employment
The term employment includes the provision of services under a contract or other arrangement.
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(6) Hospital
The term hospital has the meaning given that term in section 1861(e) of the Social Security Act ( 42 U.S.C. 1395x(e) ), 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) Staffing plan
The term staffing plan means a staffing plan required under section 2901. 3.
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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) ), as amended by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 ( Public Law 108–173 ), is amended— (1) by striking and at the end of subparagraph (U); (2) by striking the period at the end of subparagraph (V) and inserting , and ;
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and (3) by inserting after subparagraph (V) the following: (W) in the case of a hospital, to comply with the provisions of title XXIX of the Public Health Service Act. (b) Medicaid program
The first sentence of section 1902(a) of the Social Security Act ( 42 U.S.C. 1396(a) ) is amended— (1) by striking and at the end of paragraph (66); (2) by striking the period at the end of paragraph (67) and inserting ; and ;
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and (3) by inserting after paragraph (67) the following new paragraph: (68) provide that any hospital receiving payments under such plan must comply with the provisions of title XXIX of the Public Health Service Act. (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 paragraph: (7) In the case of a Department medical facility that is a hospital, the hospital shall comply with the provisions of title XXIX of the Public Health Service Act.
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(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: 1110a. 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 XXIX 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 1110 the following new item: 1110a.
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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: 826 Staffing requirements
A hospital of the Service shall comply with the provisions of title XXIX of the Public Health Service Act.. 1110a. 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 XXIX of the Public Health Service Act.
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826 Staffing requirements
A hospital of the Service shall comply with the provisions of title XXIX of the Public Health Service Act.
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1. That notwithstanding section 27 of the Merchant Marine Act , 1920 ( 46 App. U.S.C. 883 ), section 8 of the Act of June 19, 1886 ( 46 App. U.S.C. 289 ), and section 12106 of title 46, United States Code, the Secretary of Transportation may issue a certificate of documentation with appropriate endorsement for employment in the coastwise trade for the vessel W. N. RAGLAND (Washington State registration number WN5506NE).
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1. Permanent extension of credit for producing electricity from wind
Section 45(c)(3)(A) of the Internal Revenue Code of 1986 (relating to wind facility) is amended by striking , and before January 1, 2004.
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1. Modification of certain deadlines for machine-readable, tamper-resistant entry and exit documents
Section 303 of the Enhanced Border Security and Visa Entry Reform Act of 2002 ( 8 U.S.C. 1732 ) is amended, in each of subsections (b)(2)(A), (c)(1), and (c)(2), by striking 2004, and inserting 2005,.
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1. Sergeant Riayan A. Tejada Post Office
(a) Designation
The facility of the United States Postal Service located at 555 West 180th Street in New York, New York, shall be known and designated as the Sergeant Riayan A. Tejada Post Office. (b) References
Any reference in a law, map, regulation, document, paper, or other record of the United States to the facility referred to in subsection (a) shall be deemed to be a reference to the Sergeant Riayan A. Tejada Post Office.
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1. Reauthorization of National Estuary Program
Section 320(i) of the Federal Water Pollution Control Act ( 33 U.S.C. 1330(i) ) is amended by striking 2005 and inserting 2010.
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1. Short title
This Act may be cited as the “United States Economic Assistance Conditionality Act of 2004”. 2. Findings
Congress finds the following: (1) The governments of low income oil-producing countries often do not provide information to the people of such countries regarding their oil revenues. Such opacity can hide billions of dollars worth of financial impropriety. (2) The governments of such countries have generally refused to disclose information regarding their oil revenues when pressed by international organizations and others, proclaiming that such disclosure is an infringement on national sovereignty.
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(3) As a result, the people of such countries are left without the necessary information to ensure proper management and accountability regarding such oil revenues. Dispossessed, the people of such countries are often left marginalized and at the mercy of donor assistance. In Angola, for example, one in every four oil dollars earned is unaccounted for. At the same time, one in four Angolan children dies before the age of five from preventable diseases.
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(4) In some low income oil-producing countries, government-imposed royalties and fees on the revenues of business enterprises engaged in oil production are often misappropriated and squandered. These businesses are then left vulnerable to accusations of complicity with corruption. (5) The governments of low income oil-producing countries that mismanage oil revenues are often unstable and do not survive, creating further instability that threatens the supply of vital industrial commodities and forcing the international community to respond with costly emergency assistance to those countries.
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(6) A key to promoting political, economic, and social reform in low income oil-producing is transparency in public finances. (7) If the governments of such countries tell their people how much oil revenue the government receives and how that revenue is allocated and expended, the resulting transparency will engender more realistic public expectations, more plausible national development programs, and better means to combat corruption and promote democracy, respect for human rights, and the rule of law. (8) Transparency by such foreign governments will benefit United States business enterprises as well.
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Respect for the rule of law, codified regulatory practices, and transparent bidding and award practices deter corruption and encourage a level playing field in such countries for United States business enterprises. (9) Export credit activities and other bilateral concessional loan programs of the United States Government for low income oil-producing countries should require that any assistance under such activities and programs be conditional on appropriate transparency by the governments of such countries relating to oil revenues.
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