[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[S. 1709 Introduced in Senate (IS)]
<DOC>
119th CONGRESS
1st Session
S. 1709
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 SENATE OF THE UNITED STATES
May 12, 2025
Mr. Padilla (for himself, Mr. Merkley, Mr. Markey, and Ms. Warren)
introduced the following bill; which was read twice and referred to the
Committee on Health, Education, Labor, and Pensions
_______________________________________________________________________
A BILL
To amend the Public Health Service Act to establish direct care
registered nurse-to-patient staffing ratio requirements in hospitals,
and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS; FINDINGS.
(a) Short Title.--This Act may be cited as the ``Nurse Staffing
Standards for Hospital Patient Safety and Quality Care Act of 2025''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents; findings.
Sec. 2. Minimum direct care registered nurse staffing requirement.
Sec. 3. Enforcement of requirements through Federal programs.
Sec. 4. Nurse workforce initiative.
(c) Findings.--Congress finds the following:
(1) The Federal Government has a substantial interest in
promoting quality care and improving the delivery of health
care services to patients in health care facilities in the
United States.
(2) Recent changes in health care delivery systems that
have resulted in higher acuity levels among patients in health
care facilities increase the need for improved quality measures
in order to protect patient care and reduce the incidence of
medical errors.
(3) Inadequate and poorly monitored registered nurse
staffing practices that result in too few registered nurses
providing direct care jeopardize the delivery of quality health
care services.
(4) Numerous studies have shown that patient outcomes are
directly correlated to direct care registered nurse staffing
levels, including a 2010 Health Services Research study that
concluded that implementation of minimum nurse-to-patient
staffing ratios in California has led to improved patient
outcomes and nurse retention and a 2014 Agency for Healthcare
Research and Quality study that concluded increases in nurse
staffing and skill mix lead to improved quality and reduced
length of stay at no additional cost.
(5) Requirements for direct care registered nurse staffing
ratios will help address the registered nurse shortage in the
United States by aiding in recruitment of new registered nurses
and improving retention of registered nurses who are
considering leaving direct patient care because of demands
created by inadequate staffing.
(6) Establishing adequate minimum direct care registered
nurse-to-patient ratios that take into account patient acuity
measures will improve the delivery of quality health care
services and guarantee patient safety.
(7) Establishing safe staffing standards for direct care
registered nurses is a critical component of assuring that
there is adequate hospital staffing at all levels to improve
the delivery of quality care and protect patient safety.
SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE STAFFING REQUIREMENT.
(a) Minimum Direct Care Registered Nurse Staffing Requirements.--
The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by
adding at the end the following new title:
``TITLE XXXIV--MINIMUM DIRECT CARE REGISTERED NURSE STAFFING
REQUIREMENT
``SEC. 3401. MINIMUM NURSE STAFFING REQUIREMENT.
``(a) Staffing Plan.--
``(1) In general.--A hospital shall implement a staffing
plan that--
``(A) provides adequate, appropriate, and quality
delivery of health care services and protects patient
safety; and
``(B) is consistent with the requirements of this
title.
``(2) Effective dates.--
``(A) Implementation of staffing plan.--Subject to
subparagraph (B), the requirements under paragraph (1)
shall take effect on a date to be determined by the
Secretary, but not later than 1 year after the date of
the enactment of this title.
``(B) Application of minimum direct care registered
nurse-to-patient ratios.--The requirements under
subsection (b) shall take effect as soon as
practicable, as determined by the Secretary, but not
later than--
``(i) 2 years after the date of enactment
of this title; and
``(ii) in the case of a hospital in a rural
area (as defined in section 1886(d)(2)(D) of
the Social Security Act), 4 years after the
date of enactment of this title.
``(b) Minimum Direct Care Registered Nurse-To-Patient Ratios.--
``(1) In general.--Except as provided in paragraph (4) and
other provisions of this section, a hospital's staffing plan
shall provide that, at all times during each shift within a
unit of the hospital, and with a full complement of ancillary
and support staff, a direct care registered nurse may be
assigned to not more than the following number of patients in
that unit:
``(A) One patient in trauma emergency units.
``(B) One patient in operating room units, provided
that a minimum of 1 additional person serves as a scrub
assistant in such unit.
``(C) Two patients in critical care units,
including neonatal intensive care units, emergency
critical care and intensive care units, labor and
delivery units, coronary care units, acute respiratory
care units, postanesthesia units, and burn units.
``(D) Three patients in emergency room units,
pediatrics units, stepdown units, telemetry units,
antepartum units, and combined labor, deliver, and
postpartum units.
``(E) Four patients in medical-surgical units,
intermediate care nursery units, acute care psychiatric
units, and other specialty care units.
``(F) Five patients in rehabilitation units and
skilled nursing units.
``(G) Six patients in postpartum (3 couplets) units
and well-baby nursery units.
``(2) Similar units with different names.--The Secretary
may apply minimum direct care registered nurse-to-patient
ratios established in paragraph (1) for a hospital unit
referred to in such paragraph to a type of hospital unit not
referred to in such paragraph if such type of hospital unit
provides a level of care to patients whose needs are similar to
the needs of patients cared for in the hospital unit referred
to in such paragraph.
``(3) Application of ratios to hospital nursing practice
standards.--
``(A) In general.--A patient assignment may be
included in the calculation of the direct care
registered nurse-to-patient ratios required in this
subsection only if care is provided by a direct care
registered nurse and the provision of care to the
particular patient is within that direct care
registered nurse's competence.
``(B) Demonstration of unit-specific competence.--A
hospital shall not assign a direct care registered
nurse to a hospital unit unless that hospital
determines that the direct care registered nurse has
demonstrated current competence in providing care in
that unit, and has also received orientation to that
hospital's unit sufficient to provide competent care to
patients in that unit.
``(C) Duties of the assigned direct care registered
nurse.--Each patient shall be assigned to a direct care
registered nurse who shall directly provide the
assessment, planning, supervision, implementation, and
evaluation of the nursing care provided to the patient
at least every shift and has the responsibility for the
provision of care to a particular patient within his or
her scope of practice.
``(D) Nurse administrators and supervisors.--A
registered nurse who is a nurse administrator, nurse
supervisor, nurse manager, charge nurse, case manager,
or any other hospital administrator or supervisor,
shall not be included in the calculation of the direct
care registered nurse-to-patient ratio unless that
nurse has a current and active direct patient care
assignment and provides direct patient care in
compliance with the requirements of this section,
including competency requirements. The exemption in
this subsection shall apply only during the hours in
which the individual registered nurse has the principal
responsibility of providing direct patient care and has
no additional job duties as would a direct care
registered nurse.
``(E) Other personnel.--Other personnel may perform
patient care tasks based on their training and
demonstrated skill but may not perform or assist in
direct care registered nurse functions unless
authorized to do in accordance with State scope of
practice laws and regulations.
``(F) Temporary nursing personnel.--A hospital
shall not assign any nursing personnel from temporary
nursing agencies patient care to any hospital unit
without such personnel having demonstrated competence
on the assigned unit and received orientation to that
hospital's unit sufficient to provide competent care to
patients in that unit.
``(G) Ancillary and additional staffing.--The need
for additional staffing of direct care registered
nurses, licensed vocational or practical nurses,
licensed psychiatric technicians, certified nursing or
patient care assistants, or other licensed or
unlicensed ancillary staff above the minimum registered
nurse-to-patient ratios shall be based on the
assessment of the individual patient's nursing care
requirement, the individual patient's nursing care
plan, and acuity level.
``(4) Restrictions.--
``(A) Prohibition against averaging.--A hospital
shall not average the number of patients and the total
number of direct care registered nurses assigned to
patients in a hospital unit during any 1 shift or over
any period of time for purposes of meeting the
requirements under this subsection.
``(B) Prohibition against imposition of mandatory
overtime requirements.--A hospital shall not impose
mandatory overtime requirements to meet the hospital
unit direct care registered nurse-to-patient ratios
required under this subsection.
``(C) Relief during routine absences.--A hospital
shall ensure that only a direct care registered nurse
who has demonstrated current competence to the hospital
in providing care on a particular unit and has also
received orientation to that hospital's unit sufficient
to provide competent care to patients in that unit may
relieve another direct care registered nurse during
breaks, meals, and other routine, expected absences
from a hospital unit.
``(D) Application of direct care registered nurse-
to-patient ratios in patient-acuity adjustable units.--
Patients shall be cared for only on units or patient
care areas where the direct care registered nurse-to-
patient ratios meet the level of intensity, type of
care, and the individual requirements and needs of each
patient. Notwithstanding paragraph (2), hospitals that
provide patient care in units or patient care areas
that are acuity adaptable or acuity adjustable shall
apply the direct care registered nurse-to-patient ratio
required in this section for the highest patient acuity
level or level of care in that unit or patient care
area, and shall comply with all other requirements of
this section.
``(E) Use of video monitors.--A hospital shall not
employ video monitors or any form of electronic
visualization of a patient as a substitute for the
direct observation required for patient assessment by
the direct care registered nurse or required for
patient protection. Video monitors or any form of
electronic visualization of a patient shall not be
included in the calculation of the direct care
registered nurse-to-patient ratio required in this
subsection and shall not replace the requirement of
paragraph (3)(D) that each patient shall be assigned to
a direct care registered nurse who shall directly
provide the assessment, planning, supervision,
implementation, and evaluation of the nursing care
provided to the patient at least every shift and have
the responsibility for the provision of care to a
particular patient within his or her scope of practice.
``(F) Use of other technology.--A hospital shall
not employ technology that substitutes for the assigned
registered nurse's professional judgment in assessment,
planning, implementation, and evaluation of care.
``(5) Adjustment of ratios.--
``(A) In general.--If necessary to protect patient
safety, the Secretary may prescribe regulations that--
``(i) increase minimum direct care
registered nurse-to-patient ratios under this
subsection to reduce the number of patients
that may be assigned to each direct care nurse;
or
``(ii) add minimum direct care registered
nurse-to-patient ratios for units not referred
to in paragraphs (1) and (2).
``(B) Consultation.--Such regulations shall be
prescribed after consultation with affected hospitals
and registered nurses.
``(6) Ancillary and additional staffing.--
``(A) In general.--The Secretary may prescribe
regulations requiring additional staffing of direct
care registered nurses, licensed vocational or
practical nurses, licensed psychiatric technicians,
certified nursing or patient care assistants, or other
licensed or unlicensed ancillary staff above the
minimum registered nurse-to-patient ratios that is
based on the assessment of the individual patient's
nursing care needs, the individual patient's nursing
care plan, and acuity level.
``(B) Consultation.--Such regulations shall be
prescribed after consultation with affected hospitals,
registered nurses, and ancillary staff.
``(7) Relationship to state-imposed ratios.--Nothing in
this title shall preempt State standards that the Secretary
determines to be as stringent as Federal requirements for a
staffing plan established under this title. Minimum direct care
registered nurse-to-patient ratios established under this
subsection shall not preempt State requirements that the
Secretary determines are as stringent as to Federal
requirements for direct care registered nurse-to-patient ratios
established under this title.
``(8) Exemption in emergencies.--The requirements
established under this subsection shall not apply during a
state of emergency if a hospital is requested or expected to
provide an exceptional level of emergency or other medical
services. If a hospital seeks to apply the exemption under this
paragraph in response to a complaint filed against the hospital
for a violation of the provisions of this title, the hospital
must demonstrate that prompt and diligent efforts were made to
maintain required staffing levels. The Secretary shall issue
guidance to hospitals that describes situations that constitute
a state of emergency for purposes of the exemption under this
paragraph and shall establish necessary penalties for
violations of this paragraph consistent with section 3406.
``(c) Development and Reevaluation of Staffing Plan.--
``(1) Considerations in development of plan.--In developing
the staffing plan, a hospital shall provide for direct care
registered nurse-to-patient ratios above the minimum direct
care registered nurse-to-patient ratios required under
subsection (b) if appropriate based upon consideration of, at
minimum, the following factors:
``(A) The number of patients on a particular unit
on a shift-by-shift basis.
``(B) The acuity level and nursing care plan of
patients on a particular unit on a shift-by-shift
basis.