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116th Congress    }                                      {  Rept. 116-296
                        HOUSE OF REPRESENTATIVES
 1st Session      }                                       {     Part 1

======================================================================



 
   WORKPLACE VIOLENCE PREVENTION FOR HEALTH CARE AND SOCIAL SERVICE 
                              WORKERS ACT

                                _______
                                

 November 18, 2019.--Committed to the Committee of the Whole House on 
            the State of the Union and ordered to be printed

                                _______
                                

   Mr. Scott of Virginia, from the Committee on Education and Labor, 
                        submitted the following

                              R E P O R T

                             together with

                             MINORITY VIEWS

                        [To accompany H.R. 1309]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Education and Labor, to whom was referred 
the bill (H.R. 1309) to direct the Secretary of Labor to issue 
an occupational safety and health standard that requires 
covered employers within the health care and social service 
industries to develop and implement a comprehensive workplace 
violence prevention plan, and for other purposes, having 
considered the same, report favorably thereon with an amendment 
and recommend that the bill as amended do pass.

                                CONTENTS

                                                                   Page
Purpose and Summary..............................................     9
Committee Action.................................................    10
Committee Views..................................................    12
Section-by-Section Analysis......................................    29
Explanation of Amendments........................................    32
Application of Law to the Legislative Branch.....................    32
Unfunded Mandate Statement.......................................    32
Earmark Statement................................................    32
Roll Call Votes..................................................    32
Statement of Performance Goals and Objectives....................    36
Duplication of Federal Programs..................................    36
Hearings.........................................................    36
Statement of Oversight Findings and Recommendations of the 
  Committee......................................................    36
New Budget Authority and CBO Cost Estimate.......................    36
Committee Cost Estimate..........................................    40
Changes in Existing Law Made by the Bill, as Reported............    41
Appendix A.......................................................    60
Committee Correspondence.........................................    64
Minority Views...................................................    67

    The amendment is as follows:
  Strike all after the enacting clause and insert the 
following:

SECTION 1. SHORT TITLE.

  This Act may be cited as the ``Workplace Violence Prevention for 
Health Care and Social Service Workers Act''.

SEC. 2. TABLE OF CONTENTS.

  The table of contents for this Act is as follows:

Sec. 1. Short title.
Sec. 2. Table of contents.

            TITLE I--WORKPLACE VIOLENCE PREVENTION STANDARD

Sec. 101. Workplace violence prevention standard.
Sec. 102. Scope and application.
Sec. 103. Requirements for workplace violence prevention standard.
Sec. 104. Rules of construction.
Sec. 105. Other definitions.

            TITLE II--AMENDMENTS TO THE SOCIAL SECURITY ACT

Sec. 201. Application of the workplace violence prevention standard to 
certain facilities receiving Medicare funds.

            TITLE I--WORKPLACE VIOLENCE PREVENTION STANDARD

SEC. 101. WORKPLACE VIOLENCE PREVENTION STANDARD.

  (a) Interim Final Standard.--
          (1) In general.--Not later than 1 year after the date of 
        enactment of this Act, the Secretary of Labor shall promulgate 
        an interim final standard on workplace violence prevention--
                  (A) to require certain employers in the health care 
                and social service sectors, and certain employers in 
                sectors that conduct activities similar to the 
                activities in the health care and social service 
                sectors, to develop and implement a comprehensive 
                workplace violence prevention plan to protect health 
                care workers, social service workers, and other 
                personnel from workplace violence; and
                  (B) that shall, at a minimum, be based on the 
                Guidelines for Preventing Workplace Violence for Health 
                care and Social Service Workers published by the 
                Occupational Safety and Health Administration of the 
                Department of Labor in 2015 and adhere to the 
                requirements of this title.
          (2) Applicability of other statutory requirements.--The 
        following shall not apply to the promulgation of the interim 
        final standard under this subsection:
                  (A) The requirements applicable to occupational 
                safety and health standards under section 6(b) of the 
                Occupational Safety and Health Act of 1970 (29 U.S.C. 
                655(b)).
                  (B) The requirements of chapters 5 and 6 of title 5, 
                United States Code, and titles 2 and 42, United States 
                Code.
          (3) Notice and comment.--Notwithstanding paragraph (2)(B), 
        the Secretary shall, prior to promulgating the interim final 
        standard under this subsection, provide notice in the Federal 
        Register of the interim final standard and a 30-day period for 
        public comment.
          (4) Effective date of interim standard.--The interim final 
        standard shall--
                  (A) take effect on a date that is not later than 30 
                days after promulgation, except that such interim final 
                standard may include a reasonable phase-in period for 
                the implementation of required engineering controls 
                that take effect after such date;
                  (B) be enforced in the same manner and to the same 
                extent as any standard promulgated under section 6(b) 
                of the Occupational Safety and Health Act of 1970 (29 
                U.S.C. 655(b)); and
                  (C) be in effect until the final standard described 
                in subsection (b) becomes effective and enforceable.
          (5) Failure to promulgate.--If an interim final standard 
        described in paragraph (1) is not promulgated not later than 1 
        year of the date of enactment of this Act, the provisions of 
        this title shall be in effect and enforced in the same manner 
        and to the same extent as any standard promulgated under 
        section 6(b) of the Occupational Safety and Health Act (29 
        U.S.C. 655(b)) until such provisions are superseded in whole by 
        an interim final standard promulgated by the Secretary that 
        meets the requirements of paragraph (1).
  (b) Final Standard.--
          (1) Proposed standard.--Not later than 2 years after the date 
        of enactment of this Act, the Secretary of Labor shall, 
        pursuant to section 6 of the Occupational Safety and Health Act 
        (29 U.S.C. 655), promulgate a proposed standard on workplace 
        violence prevention--
                  (A) for the purposes described in subsection 
                (a)(1)(A); and
                  (B) that shall include, at a minimum, the elements 
                contained in the interim final standard promulgated 
                under subsection (a).
          (2) Final standard.--Not later than 42 months after the date 
        of enactment of this Act, the Secretary shall promulgate a 
        final standard on such proposed standard that shall--
                  (A) provide no less protection than any workplace 
                violence standard adopted by a State plan that has been 
                approved by the Secretary under section 18 of the 
                Occupational Safety and Health Act of 1970 (29 U.S.C. 
                667); and
                  (B) be effective and enforceable in the same manner 
                and to the same extent as any standard promulgated 
                under section 6(b) of the Occupational Safety and 
                Health Act of 1970 (29 U.S.C. 655(b)).

SEC. 102. SCOPE AND APPLICATION.

  In this title:
          (1) Covered facility.--The term ``covered facility'' includes 
        the following:
                  (A) Any hospital, including any specialty hospital, 
                in-patient or outpatient setting, or clinic operating 
                within a hospital license, or any setting that provides 
                outpatient services.
                  (B) Any residential treatment facility, including any 
                nursing home, skilled nursing facility, hospice 
                facility, and long-term care facility.
                  (C) Any non-residential treatment or service setting.
                  (D) Any medical treatment or social service setting 
                or clinic at a correctional or detention facility.
                  (E) Any community care setting, including a 
                community-based residential facility, group home, and 
                mental health clinic.
                  (F) Any psychiatric treatment facility.
                  (G) Any drug abuse or substance use disorder 
                treatment center.
                  (H) Any independent freestanding emergency centers.
                  (I) Any facility described in subparagraphs (A) 
                through (H) operated by a Federal Government agency and 
                required to comply with occupational safety and health 
                standards pursuant to section 1960 of title 29, Code of 
                Federal Regulations (as such section is in effect on 
                the date of enactment of this Act).
                  (J) Any other facility the Secretary determines 
                should be covered under the standards promulgated under 
                section 101.
          (2) Covered services.--The term ``covered service'' includes 
        the following services and operations:
                  (A) Any services and operations provided in any field 
                work setting, including home health care, home-based 
                hospice, and home-based social work.
                  (B) Any emergency services and transport, including 
                such services provided by firefighters and emergency 
                responders.
                  (C) Any services described in subparagraphs (A) and 
                (B) performed by a Federal Government agency and 
                required to comply with occupational safety and health 
                standards pursuant to section 1960 of title 29, Code of 
                Federal Regulations (as such section is in effect on 
                the date of enactment of this Act).
                  (D) Any other services and operations the Secretary 
                determines should be covered under the standards 
                promulgated under section 101.
          (3) Covered employer.--
                  (A) In general.--The term ``covered employer'' 
                includes a person (including a contractor, 
                subcontractor, a temporary service firm, or an employee 
                leasing entity) that employs an individual to work at a 
                covered facility or to perform covered services.
                  (B) Exclusion.--The term ``covered employer'' does 
                not include an individual who privately employs, in the 
                individual's residence, a person to perform covered 
                services for the individual or a family member of the 
                individual.
          (4) Covered employee.--The term ``covered employee'' includes 
        an individual employed by a covered employer to work at a 
        covered facility or to perform covered services.

SEC. 103. REQUIREMENTS FOR WORKPLACE VIOLENCE PREVENTION STANDARD.

  Each standard described in section 101 shall include, at a minimum, 
the following requirements:
          (1) Workplace violence prevention plan.--Not later than 6 
        months after the date of promulgation of the interim final 
        standard under section 101(a), a covered employer shall 
        develop, implement, and maintain an effective written workplace 
        violence prevention plan for covered employees at each covered 
        facility and for covered employees performing a covered service 
        on behalf of such employer, which meets the following:
                  (A) Plan development.--Each Plan shall--
                          (i) be developed and implemented with the 
                        meaningful participation of direct care 
                        employees, other employees, and employee 
                        representatives, for all aspects of the Plan;
                          (ii) be tailored and specific to conditions 
                        and hazards for the covered facility or the 
                        covered service, including patient-specific 
                        risk factors and risk factors specific to each 
                        work area or unit; and
                          (iii) be suitable for the size, complexity, 
                        and type of operations at the covered facility 
                        or for the covered service, and remain in 
                        effect at all times.
                  (B) Plan content.--Each Plan shall include procedures 
                and methods for the following:
                          (i) Identification of the individual 
                        responsible for implementation of the Plan.
                          (ii) With respect to each work area and unit 
                        at the covered facility or while covered 
                        employees are performing the covered service, 
                        risk assessment and identification of workplace 
                        violence risks and hazards to employees exposed 
                        to such risks and hazards (including 
                        environmental risk factors and patient-specific 
                        risk factors), which shall be--
                                  (I) informed by past violent 
                                incidents specific to such covered 
                                facility or such covered service; and
                                  (II) conducted with, at a minimum--
                                          (aa) direct care employees;
                                          (bb) where applicable, the 
                                        representatives of such 
                                        employees; and
                                          (cc) the employer.
                          (iii) Hazard prevention, engineering 
                        controls, or work practice controls to correct 
                        hazards, in a timely manner, applying 
                        industrial hygiene principles of the hierarchy 
                        of controls, which--
                                  (I) may include security and alarm 
                                systems, adequate exit routes, 
                                monitoring systems, barrier protection, 
                                established areas for patients and 
                                clients, lighting, entry procedures, 
                                staffing and working in teams, and 
                                systems to identify and flag clients 
                                with a history of violence; and
                                  (II) shall ensure that employers 
                                correct, in a timely manner, hazards 
                                identified in any violent incident 
                                investigation described in paragraph 
                                (2) and any annual report described in 
                                paragraph (5).
                          (iv) Reporting, incident response, and post-
                        incident investigation procedures, including 
                        procedures--
                                  (I) for employees to report workplace 
                                violence risks, hazards, and incidents;
                                  (II) for employers to respond to 
                                reports of workplace violence;
                                  (III) for employers to perform a 
                                post-incident investigation and 
                                debriefing of all reports of workplace 
                                violence with the participation of 
                                employees and their representatives; 
                                and
                                  (IV) to provide medical care or first 
                                aid to affected employees.
                          (v) Procedures for emergency response, 
                        including procedures for threats of mass 
                        casualties and procedures for incidents 
                        involving a firearm or a dangerous weapon.
                          (vi) Procedures for communicating with and 
                        training the covered employees on workplace 
                        violence hazards, threats, and work practice 
                        controls, the employer's plan, and procedures 
                        for confronting, responding to, and reporting 
                        workplace violence threats, incidents, and 
                        concerns, and employee rights.
                          (vii) Procedures for--
                                  (I) ensuring the coordination of risk 
                                assessment efforts, Plan development, 
                                and implementation of the Plan with 
                                other employers who have employees who 
                                work at the covered facility or who are 
                                performing the covered service; and
                                  (II) determining which covered 
                                employer or covered employers shall be 
                                responsible for implementing and 
                                complying with the provisions of the 
                                standard applicable to the working 
                                conditions over which such employers 
                                have control.
                          (viii) Procedures for conducting the annual 
                        evaluation under paragraph (6).
                  (C) Availability of plan.--Each Plan shall be made 
                available at all times to the covered employees who are 
                covered under such Plan.
          (2) Violent incident investigation.--
                  (A) In general.--As soon as practicable after a 
                workplace violence incident, risk, or hazard of which a 
                covered employer has knowledge, the employer shall 
                conduct an investigation of such incident, risk, or 
                hazard under which the employer shall--
                          (i) review the circumstances of the incident, 
                        risk, or hazard, and whether any controls or 
                        measures implemented pursuant to the Plan of 
                        the employer were effective; and
                          (ii) solicit input from involved employees, 
                        their representatives, and supervisors about 
                        the cause of the incident, risk, or hazard, and 
                        whether further corrective measures (including 
                        system-level factors) could have prevented the 
                        incident, risk, or hazard.
                  (B) Documentation.--A covered employer shall document 
                the findings, recommendations, and corrective measures 
                taken for each investigation conducted under this 
                paragraph.
          (3) Training and education.--With respect to the covered 
        employees covered under a Plan of a covered employer, the 
        employer shall provide training and education to such employees 
        who may be exposed to workplace violence hazards and risks, 
        which meet the following requirements:
                  (A) Annual training and education shall include 
                information on the Plan, including identified workplace 
                violence hazards, work practice control measures, 
                reporting procedures, record keeping requirements, 
                response procedures, and employee rights.
                  (B) Additional hazard recognition training shall be 
                provided for supervisors and managers to ensure they--
                          (i) can recognize high-risk situations; and
                          (ii) do not assign employees to situations 
                        that predictably compromise the safety of such 
                        employees.
                  (C) Additional training shall be provided for each 
                such covered employee whose job circumstances have 
                changed, within a reasonable timeframe after such 
                change.
                  (D) Applicable training shall be provided under this 
                paragraph for each new covered employee prior to the 
                employee's job assignment.
                  (E) All training shall provide such employees 
                opportunities to ask questions, give feedback on 
                training, and request additional instruction, 
                clarification, or other followup.
                  (F) All training shall be provided in-person and by 
                an individual with knowledge of workplace violence 
                prevention and of the Plan, except that any annual 
                training described in subparagraph (A) provided to an 
                employee after the first year such training is provided 
                to such employee may be conducted by live video if in-
                person training is impracticable.
                  (G) All training shall be appropriate in content and 
                vocabulary to the language, educational level, and 
                literacy of such covered employees.
          (4) Recordkeeping and access to plan records.--
                  (A) In general.--Each covered employer shall--
                          (i) maintain for not less than 5 years--
                                  (I) records related to each Plan of 
                                the employer, including workplace 
                                violence risk and hazard assessments, 
                                and identification, evaluation, 
                                correction, and training procedures;
                                  (II) a violent incident log described 
                                in subparagraph (B) for recording all 
                                workplace violence incidents; and
                                  (III) records of all incident 
                                investigations as required under 
                                paragraph (2)(B); and
                          (ii)(I) make such records and logs available, 
                        upon request, to covered employees and their 
                        representatives for examination and copying in 
                        accordance with section 1910.1020 of title 29, 
                        Code of Federal Regulations (as such section is 
                        in effect on the date of enactment of this 
                        Act), and in a manner consistent with HIPAA 
                        privacy regulations (defined in section 
                        1180(b)(3) of the Social Security Act (42 
                        U.S.C. 1320d-9(b)(3))) and part 2 of title 42, 
                        Code of Federal Regulations (as such part is in 
                        effect on the date of enactment of this Act); 
                        and
                          (II) ensure that any such records and logs 
                        that may be copied, transmitted electronically, 
                        or otherwise removed from the employer's 
                        control for purposes of this clause omit any 
                        element of personal identifying information 
                        sufficient to allow identification of any 
                        patient, resident, client, or other individual 
                        alleged to have committed a violent incident 
                        (including the individual's name, address, 
                        electronic mail address, telephone number, or 
                        social security number, or other information 
                        that, alone or in combination with other 
                        publicly available information, reveals such 
                        individual's identity).
                  (B) Violent incident log description.--Each violent 
                incident log shall--
                          (i) be maintained by a covered employer for 
                        each covered facility controlled by the 
                        employer and for each covered service being 
                        performed by a covered employee on behalf of 
                        such employer;
                          (ii) be based on a template developed by the 
                        Secretary not later than 1 year after the date 
                        of enactment of this Act;
                          (iii) include, at a minimum, a description 
                        of--
                                  (I) the violent incident (including 
                                environmental risk factors present at 
                                the time of the incident);
                                  (II) the date, time, and location of 
                                the incident, and the names and job 
                                titles of involved employees;
                                  (III) the nature and extent of 
                                injuries to covered employees;
                                  (IV) a classification of the 
                                perpetrator who committed the violence, 
                                including whether the perpetrator was--
                                          (aa) a patient, client, 
                                        resident, or customer of a 
                                        covered employer;
                                          (bb) a family or friend of a 
                                        patient, client, resident, or 
                                        customer of a covered employer;
                                          (cc) a stranger;
                                          (dd) a coworker, supervisor, 
                                        or manager of a covered 
                                        employee;
                                          (ee) a partner, spouse, 
                                        parent, or relative of a 
                                        covered employee; or
                                          (ff) any other appropriate 
                                        classification;
                                  (V) the type of violent incident 
                                (such as type 1 violence, type 2 
                                violence, type 3 violence, or type 4 
                                violence); and
                                  (VI) how the incident was abated;
                          (iv) not later than 7 days after the employer 
                        learns of such incident, contain a record of 
                        each violent incident, which is updated to 
                        ensure completeness of such record;
                          (v) be maintained for not less than 5 years; 
                        and
                          (vi) in the case of a violent incident 
                        involving a privacy concern case, protect the 
                        identity of employees in a manner consistent 
                        with section 1904.29(b) of title 29, Code of 
                        Federal Regulations (as such section is in 
                        effect on the date of enactment of this Act).
                  (C) Annual summary.--
                          (i) Covered employers.--Each covered employer 
                        shall prepare an annual summary of each violent 
                        incident log for the preceding calendar year 
                        that shall--
                                  (I) with respect to each covered 
                                facility, and each covered service, for 
                                which such a log has been maintained, 
                                include the total number of violent 
                                incidents, the number of recordable 
                                injuries related to such incidents, and 
                                the total number of hours worked by the 
                                covered employees for such preceding 
                                year;
                                  (II) be completed on a form provided 
                                by the Secretary;
                                  (III) be posted for three months 
                                beginning February 1 of each year in a 
                                manner consistent with the requirements 
                                of section 1904 of title 29, Code of 
                                Federal Regulations (as such section is 
                                in effect on the date of enactment of 
                                this Act), relating to the posting of 
                                summaries of injury and illness logs;
                                  (IV) be located in a conspicuous 
                                place or places where notices to 
                                employees are customarily posted; and
                                  (V) not be altered, defaced, or 
                                covered by other material.
                          (ii) Secretary.--Not later than 1 year after 
                        the promulgation of the interim final standard 
                        under section 101(a), the Secretary shall make 
                        available a platform for the electronic 
                        submission of annual summaries required under 
                        this paragraph.
          (5) Annual report.--Not later than February 15 of each year, 
        each covered employer shall report to the Secretary, the 
        frequency, quantity, and severity of workplace violence, and 
        any incident response and post-incident investigation 
        (including abatement measures) for the incidents set forth in 
        the annual summary of the violent incident log described in 
        paragraph (4)(C).
          (6) Annual evaluation.--Each covered employer shall conduct 
        an annual written evaluation, conducted with the full, active 
        participation of covered employees and employee 
        representatives, of--
                  (A) the implementation and effectiveness of the Plan, 
                including a review of the violent incident log; and
                  (B) compliance with training required by each 
                standard described in section 101, and specified in the 
                Plan.
          (7) Anti-retaliation.--
                  (A) Policy.--Each covered employer shall adopt a 
                policy prohibiting any person (including an agent of 
                the employer) from discriminating or retaliating 
                against any employee for reporting, or seeking 
                assistance or intervention from, a workplace violence 
                incident, threat, or concern to the employer, law 
                enforcement, local emergency services, or a government 
                agency, or participating in an incident investigation.
                  (B) Prohibition.--No covered employer shall 
                discriminate or retaliate against any employee for--
                          (i) reporting a workplace violence incident, 
                        threat, or concern to, or seeking assistance or 
                        intervention with respect to such incident, 
                        threat, or concern from, the employer, law 
                        enforcement, local emergency services, or a 
                        local, State, or Federal government agency; or
                          (ii) exercising any other rights under this 
                        paragraph.
                  (C) Enforcement.--This paragraph shall be enforced in 
                the same manner and to the same extent as any standard 
                promulgated under section 6(b) of the Occupational 
                Safety and Health Act (29 U.S.C. 655(b)).

SEC. 104. RULES OF CONSTRUCTION.

  Notwithstanding section 18 of the Occupational Safety and Health Act 
of 1970 (29 U.S.C. 667)--
          (1) nothing in this title shall be construed to curtail or 
        limit authority of the Secretary under any other provision of 
        the law; and
          (2) the rights, privileges, or remedies of covered employees 
        shall be in addition to the rights, privileges, or remedies 
        provided under any Federal or State law, or any collective 
        bargaining agreement.

SEC. 105. OTHER DEFINITIONS.

  In this title:
          (1) Workplace violence.--
                  (A) In general.--The term ``workplace violence'' 
                means any act of violence or threat of violence, 
                without regard to intent, that occurs at a covered 
                facility or while a covered employee performs a covered 
                service.
                  (B) Exclusions.--The term ``workplace violence'' does 
                not include lawful acts of self-defense or lawful acts 
                of defense of others.
                  (C) Inclusions.--The term ``workplace violence'' 
                includes--
                          (i) the threat or use of physical force 
                        against a covered employee that results in or 
                        has a high likelihood of resulting in injury, 
                        psychological trauma, or stress, without regard 
                        to whether the covered employee sustains an 
                        injury, psychological trauma, or stress; and
                          (ii) an incident involving the threat or use 
                        of a firearm or a dangerous weapon, including 
                        the use of common objects as weapons, without 
                        regard to whether the employee sustains an 
                        injury, psychological trauma, or stress.
          (2) Type 1 violence.--The term ``type 1 violence''--
                  (A) means workplace violence directed at a covered 
                employee at a covered facility or while performing a 
                covered service by an individual who has no legitimate 
                business at the covered facility or with respect to 
                such covered service; and
                  (B) includes violent acts by any individual who 
                enters the covered facility or worksite where a covered 
                service is being performed with the intent to commit a 
                crime.
          (3) Type 2 violence.--The term ``type 2 violence'' means 
        workplace violence directed at a covered employee by customers, 
        clients, patients, students, inmates, or any individual for 
        whom a covered facility provides services or for whom the 
        employee performs covered services.
          (4) Type 3 violence.--The term ``type 3 violence'' means 
        workplace violence directed at a covered employee by a present 
        or former employee, supervisor, or manager.
          (5) Type 4 violence.--The term ``type 4 violence'' means 
        workplace violence directed at a covered employee by an 
        individual who is not an employee, but has or is known to have 
        had a personal relationship with such employee, or with a 
        customer, client, patient, student, inmate, or any individual 
        for whom a covered facility provides services or for whom the 
        employee performs covered services.
          (6) Threat of violence.--The term ``threat of violence'' 
        means a statement or conduct that--
                  (A) causes an individual to fear for such 
                individual's safety because there is a reasonable 
                possibility the individual might be physically injured; 
                and
                  (B) serves no legitimate purpose.
          (7) Alarm.--The term ``alarm'' means a mechanical, 
        electrical, or electronic device that does not rely upon an 
        employee's vocalization in order to alert others.
          (8) Dangerous weapon.--The term ``dangerous weapon'' means an 
        instrument capable of inflicting death or serious bodily 
        injury, without regard to whether such instrument was designed 
        for that purpose.
          (9) Engineering controls.--
                  (A) In general.--The term ``engineering controls'' 
                means an aspect of the built space or a device that 
                removes a hazard from the workplace or creates a 
                barrier between a covered employee and the hazard.
                  (B) Inclusions.--For purposes of reducing workplace 
                violence hazards, the term ``engineering controls'' 
                includes electronic access controls to employee 
                occupied areas, weapon detectors (installed or 
                handheld), enclosed workstations with shatter-resistant 
                glass, deep service counters, separate rooms or areas 
                for high-risk patients, locks on doors, removing access 
                to or securing items that could be used as weapons, 
                furniture affixed to the floor, opaque glass in patient 
                rooms (which protects privacy, but allows the health 
                care provider to see where the patient is before 
                entering the room), closed-circuit television 
                monitoring and video recording, sight-aids, and 
                personal alarm devices.
          (10) Environmental risk factors.--
                  (A) In general.--The term ``environmental risk 
                factors'' means factors in the covered facility or area 
                in which a covered service is performed that may 
                contribute to the likelihood or severity of a workplace 
                violence incident.
                  (B) Clarification.--Environmental risk factors may be 
                associated with the specific task being performed or 
                the work area, such as working in an isolated area, 
                poor illumination or blocked visibility, and lack of 
                physical barriers between individuals and persons at 
                risk of committing workplace violence.
          (11) Patient-specific risk factors.--The term ``patient-
        specific risk factors'' means factors specific to a patient 
        that may increase the likelihood or severity of a workplace 
        violence incident, including--
                  (A) a patient's treatment and medication status, and 
                history of violence and use of drugs or alcohol; and
                  (B) any conditions or disease processes of the 
                patient that may cause the patient to experience 
                confusion or disorientation, be non-responsive to 
                instruction, behave unpredictably, or engage in 
                disruptive, threatening, or violent behavior.
          (12) Secretary.--The term ``Secretary'' means the Secretary 
        of Labor.
          (13) Work practice controls.--
                  (A) In general.--The term ``work practice controls'' 
                means procedures and rules that are used to effectively 
                reduce workplace violence hazards.
                  (B) Inclusions.--The term ``work practice controls'' 
                includes--
                          (i) assigning and placing sufficient numbers 
                        of staff to reduce patient-specific Type 2 
                        workplace violence hazards;
                          (ii) provision of dedicated and available 
                        safety personnel such as security guards;
                          (iii) employee training on workplace violence 
                        prevention methods and techniques to de-
                        escalate and minimize violent behavior; and
                          (iv) employee training on procedures for 
                        response in the event of a workplace violence 
                        incident and for post-incident response.

            TITLE II--AMENDMENTS TO THE SOCIAL SECURITY ACT

SEC. 201. APPLICATION OF THE WORKPLACE VIOLENCE PREVENTION STANDARD TO 
                    CERTAIN FACILITIES RECEIVING MEDICARE FUNDS.

  (a) In General.--Section 1866 of the Social Security Act (42 U.S.C. 
1395cc) is amended--
          (1) in subsection (a)(1)--
                  (A) in subparagraph (X), by striking ``and'' at the 
                end;
                  (B) in subparagraph (Y), by striking at the end the 
                period and inserting ``; and''; and
                  (C) by inserting after subparagraph (Y) the following 
                new subparagraph:
          ``(Z) in the case of hospitals that are not otherwise subject 
        to the Occupational Safety and Health Act of 1970 (or a State 
        occupational safety and health plan that is approved under 
        18(b) of such Act) and skilled nursing facilities that are not 
        otherwise subject to such Act (or such a State occupational 
        safety and health plan), to comply with the Workplace Violence 
        Prevention Standard (as promulgated under section 101 of the 
        Workplace Violence Prevention for Health Care and Social 
        Service Workers Act).''; and
          (2) in subsection (b)(4)--
                  (A) in subparagraph (A), by inserting ``and a 
                hospital or skilled nursing facility that fails to 
                comply with the requirement of subsection (a)(1)(Z) 
                (relating to the Workplace Violence Prevention 
                Standard)'' after ``Bloodborne Pathogens standard)''; 
                and
                  (B) in subparagraph (B)--
                          (i) by striking ``(a)(1)(U)'' and inserting 
                        ``(a)(1)(V)''; and
                          (ii) by inserting ``(or, in the case of a 
                        failure to comply with the requirement of 
                        subsection (a)(1)(Z), for a violation of the 
                        Workplace Violence Prevention standard referred 
                        to in such subsection by a hospital or skilled 
                        nursing facility, as applicable, that is 
                        subject to the provisions of such Act)'' before 
                        the period at the end.
  (b) Effective Date.--The amendments made by subsection (a) shall 
apply beginning on the date that is 1 year after the date of issuance 
of the interim final standard on workplace violence prevention required 
under section 101.

                          Purpose and Summary

    The purpose of H.R. 1309, the Workplace Violence Prevention 
for Health Care and Social Service Workers Act, is to direct 
the Occupational Safety and Health Administration (OSHA) to 
issue within 42 months a federal workplace violence prevention 
standard to protect workers in the health care and social 
services sectors. H.R. 1309 also requires hospitals and skilled 
nursing facilities that receive Medicare funds and that are 
operated by state or local governments in states that are not 
subject to the jurisdiction of the Occupational Safety and 
Health Act of 1970 (OSH Act) or a state OSHA plan to comply 
with the workplace violence prevention standard to be issued by 
OSHA.
    Health care and social service workers are at high risk of 
assault by patients, clients, and members of the public. Peer 
reviewed studies and Bureau of Labor Statistics data show high 
injury rates from workplace violence for these workers.\1\ 
Furthermore, assaults on health care and social service workers 
are underreported, because reporting practices are burdensome, 
many health care and social service workers perceive such 
violence as part of their job, and they are often disciplined 
for reporting assaults.\2\ Data shows public employees are at 
even higher risk, but they are not covered by Federal or state 
OSHA in 24 states.
---------------------------------------------------------------------------
    \1\Bureau of Labor Statistics, Survey of Occupational Injuries and 
Illnesses (2017), https://www.bls.gov/web/osh/cd_r8.htm.
    \2\Sentinel Event Alert, Physical and Verbal Violence Against 
Health Care Workers 2 (2018), https://www.jointcommission.org/assets/1/
18/SEA_59_Workplace_violence_4_13_18_FINAL.pdf.
---------------------------------------------------------------------------
    Federal OSHA does not currently have an enforceable 
standard that requires employers to adopt or implement a 
workplace violence prevention program, and it typically takes 
OSHA decades to issue final standards absent congressional 
direction. Although OSHA has issued and updated voluntary 
guidelines delineating best practices for preventing violence 
in health care and social service settings, and OSHA has 
provided employers with compliance assistance for over 20 
years, voluntary efforts alone have proven insufficient. 
Government statistics show the problem is growing in the health 
care and social service sectors.
    H.R. 1309 would ensure that health care and social service 
workplaces adopt violence prevention plans to prevent or 
mitigate violent incidents in the workplace using proven 
prevention techniques tailored to the risks in a given 
workplace. An OSHA standard would strengthen protections for 
workers where employers are failing to take the appropriate 
protective measures or have no kind of plan to address the 
problem.

                            Committee Action


                             115TH CONGRESS

    On March 8, 2018, Representative Ro Khanna (D-CA-17) 
introduced H.R. 5223, the Health Care Workplace Violence 
Prevention Act. The bill requires OSHA to address workplace 
violence in health care facilities by issuing a workplace 
violence prevention standard within two years of enactment that 
would require certain health care employers to adopt a 
comprehensive plan for protecting workers and other personnel 
from workplace violence. The bill was referred to the Committee 
on Education and the Workforce as well as the Committees on 
Energy and Commerce and Ways and Means.
    On November 16, 2018, Representative Joe Courtney (D-CT-2) 
introduced H.R. 7141, the Workplace Violence Prevention for 
Health Care and Social Service Workers Act. The bill directs 
OSHA to issue a workplace violence prevention standard that 
requires certain employers in the health care and social 
service sectors to develop and implement a comprehensive plan 
for protecting workers from workplace violence. H.R. 7141 
directs OSHA to issue an interim final standard within one year 
of enactment, to propose a final standard within two years of 
enactment, and to issue a final standard within 42 months. The 
OSHA standard should, at a minimum, be based on the OSHA 
Guidelines for Preventing Workplace Violence for Healthcare and 
Social Service Workers. The bill was referred to the Committee 
on Education and the Workforce as well as the Committees on 
Energy and Commerce and Ways and Means.

                             116TH CONGRESS

    On February 19, 2019, Representative Joe Courtney 
introduced H.R. 1309, the Workplace Violence Prevention for 
Health Care and Social Service Workers Act. The bill directs 
OSHA to issue a workplace violence prevention standard that 
requires certain employers in the health care and social 
service sectors to develop and implement a comprehensive plan 
for protecting workers from workplace violence. H.R. 1309 
directs OSHA to issue an interim final standard within one year 
of enactment, to propose a final standard within two years of 
enactment, and to issue a final standard within 42 months. The 
OSHA standard should, at a minimum, be based on the OSHA 
Guidelines for Preventing Workplace Violence for Healthcare and 
Social Service Workers (Guidelines.)\3\ The bill was referred 
to the Committee on Education and Labor as well as the 
Committees on Energy and Commerce and Ways and Means.
---------------------------------------------------------------------------
    \3\Occupational Safety and Health Administration, Guidelines for 
Preventing Workplace Violence for Health Care and Social Service 
Workers, 5, (2016), https://www.osha.gov/Publications/osha3148.pdf.
---------------------------------------------------------------------------
    On February 27, 2019, the Workforce Protections 
Subcommittee of the Committee on Education and Labor held a 
legislative hearing entitled ``Caring for the Caregivers: 
Protecting Health Care and Social Service Workers from 
Workplace Violence'' (WP Subcommittee Hearing). The hearing 
assessed the severity of workplace violence, examined the steps 
taken by OSHA, and considered the merits of legislation 
requiring OSHA to issue a violence prevention standard compared 
with continued reliance on voluntary guidelines. The 
Subcommittee heard testimony on the hazards of workplace 
violence faced by health care and social service workers, 
successful strategies for addressing and mitigating the 
hazards, and how the provisions outlined in H.R. 1309 will make 
workplaces safer. Witnesses included Angelo McClain, PhD, 
LICSW, Chief Executive Officer, National Association of Social 
Workers; Patricia Moon-Updike, RN, former Psychiatric RN in the 
Child and Adolescent Treatment Unit of the Behavioral Health 
Division of Milwaukee County, representing the American 
Federation of Teachers; Dr. Jane Lipscomb, an expert on 
workplace violence; and Manesh K. Rath, a partner at the law 
firm Keller and Heckman.
    On March 14, 2019, Senator Tammy Baldwin (D-WI) introduced 
S. 851, the Workplace Violence Prevention for Health Care and 
Social Service Workers Act, which is the Senate companion to 
H.R. 1309. S. 851 directs OSHA to issue an occupational safety 
and health standard that requires covered employers within the 
health care and social service industries to develop and 
implement a comprehensive workplace violence prevention plan. 
The bill was referred to the Senate Committee on Health, 
Education, Labor and Pensions.
    On June 11, 2019, the House Committee on Education and 
Labor met for a full committee markup of H.R. 1309, the 
Workplace Violence Prevention for Health Care and Social 
Service Workers Act, and reported it favorably, as amended, to 
the House of Representatives by a vote of 26-18.
    The Committee on Education and Labor considered the 
following amendments to H.R. 1309:
    (1) An amendment in the nature of a substitute (ANS) was 
offered by Representative Joe Courtney. The ANS incorporates 
the provisions of H.R. 1309 with the following modifications:
           establishes procedures for determining which 
        covered employer or employers have responsibility for 
        implementing and complying with the provisions of the 
        standard in workplaces with multiple employers;
           excludes disclosure of ``a patient's 
        psychiatric condition'' as part of reviewing ``patient-
        specific risk factors'' to better protect the 
        confidential information of patients;
           allows annual refresher training conducted 
        by live video conferencing if in-person training is 
        impracticable; and
           makes technical corrections to ensure that 
        congressional intent is clear.
    (2) An amendment was offered by Representative Haley 
Stevens (D-MI-11) that requires OSHA to provide a 30-day public 
comment period prior to the issuance of an interim final 
standard. The amendment was adopted by a voice vote.
    (3) A substitute amendment to the ANS was offered by 
Representative Bradley Byrne (R-AL-1). Amongst its provisions, 
the amendment requires OSHA to issue a final workplace violence 
prevention standard, however, it fails to: include any 
deadline; precede the final standard with an interim final 
standard; require that an annual summary of violent incidents 
be transmitted to OSHA; include language prohibiting employers 
from retaliating against an employee for reporting a workplace 
violence incident or for seeking assistance or intervention 
from the employer, law enforcement, emergency services, or a 
state or local agency; and provide OSHA with authority to 
administratively enforce, and order abatement of an employer's 
violations of the anti-retaliation standard. In other words, it 
effectively removes any of the teeth that the base bill 
includes. The amendment was rejected by a vote of 20 yeas to 25 
nays.
    (4) The ANS, as amended, was adopted by voice vote as the 
bill, as amended was reported favorably to the House by a vote 
of 26-18.

                            Committee Views

    The Committee on Education and Labor (Committee) is 
committed to protecting the health and safety of our nation's 
workers. According to a 2016 Government Accountability Office 
(GAO) report entitled Workplace Safety and Health: Additional 
Efforts Needed to Help Protect Health Care Workers from 
Workplace Violence, workplace violence is a serious concern for 
15 million health care workers in the United States.\4\ 
Although health care facilities are viewed as a place to get 
well, the reality is that day-to-day work in these facilities 
exposes many employees to an unacceptably high risk of violent 
injury--originating in almost all cases from patients, clients 
and residents. Federal injury data shows that the rates of 
workplace violence at health care facilities are high and 
rising. At state-run nursing and residential care facilities, 
the rates of serious injuries are higher than those in steel 
foundries, coal mines, hog farms or state prisons. OSHA does 
not require employers to have workplace violence prevention 
programs, but several states have enacted laws to better 
protect health care workers. Following the aforementioned GAO 
report and petitions for rulemaking, OSHA started work on an 
enforceable violence prevention standard at the end of the 
Obama Administration. There has been negligible progress in the 
past 33 months since the Trump Administration took over.
---------------------------------------------------------------------------
    \4\United States Government Accountability Office, Workplace Safety 
and Health: Additional Efforts Needed to Help Protect Health Care 
Workers from Workplace Violence (2016), https://www.gao.gov/assets/680/
675858.pdf.
---------------------------------------------------------------------------
    H.R. 1309, the Workplace Violence Prevention for Health 
Care and Social Service Workers Act, was introduced to require 
OSHA to issue an interim final standard within one year, to 
issue a workplace violence prevention standard within 42 
months, and to specify the main elements that must be included 
in an OSHA standard.
    H.R. 1309 has been endorsed by the AFL-CIO, American 
Industrial Hygiene Association, Alliance for Retired Americans, 
American Art Therapy Association, American Association for 
Psychoanalysis in Clinical Social Work, American College of 
Emergency Physicians, American College of Occupational and 
Environmental Medicine, American Counseling Association, 
American Federation of Government Employees, American 
Federation of State, County and Municipal Employees, American 
Federation of Teachers, American Nurses Association, American 
Psychiatric Association, American Psychiatric Nurses 
Association, American Public Health Association, American 
Society of Safety Professionals, Coalition of Labor Union Women 
of Southwestern P.A., Communications Workers of America, 
Connecticut Association of Nurse Anesthetists, ElevatingHOME, 
Emergency Nurses Association, International Association of Fire 
Fighters, International Association of Machinists and Aerospace 
Workers, Massachusetts Nurses Association, Michigan Nurses 
Association, Midstate Education and Service Foundation, 
National Association of County Behavioral Health & Development 
Disability Directors, National Association of Emergency Medical 
Technicians, National Association of Rural Mental Health, 
National Association of Social Workers, National Council for 
Occupational Safety and Health, National Nurses United, New 
York Nurses Association, Philadelphia Area Project on 
Occupational Safety and Health, Public Citizen, Rhode Island 
Committee on Occupational Safety and Health, School Social Work 
Association of America, Service Employees International Union, 
Smart Transportation, Teamsters, United Auto Workers, United 
Steelworkers, and Worksafe.

Workers Are Paying the Price of Inaction

     According to the Bureau of Labor Statistics (BLS), in 
2017, hospital workers were nearly five times as likely to 
suffer a serious workplace violence injury than all other 
workers, while workers in psychiatric hospitals are at 45 times 
greater risk of workplace violence injuries compared with all 
other workers.\5\ BLS reports 19,740 health and social service 
workers had injuries so severe they lost workdays from injuries 
due to workplace violence in 2017, amounting to 68 percent of 
all workplace violence injuries across all industries.\6\
---------------------------------------------------------------------------
    \5\Bureau of Labor Statistics, Survey of Occupational Injuries and 
Illnesses (2017), https://www.bls.gov/web/osh/cd_r8.htm, (Incidence 
rates of violence for nonfatal occupational injuries and illnesses 
involving days away from work.).
    \6\Bureau of Labor Statistics, Survey of Occupational Injuries and 
Illnesses (2017), https://www.bls.gov/iif/oshwc/osh/case/cd_r4_2017.htm 
(Number of nonfatal occupational injuries and illnesses involving days 
away from work by industry and selected events or exposures leading to 
injury or illness, private industry.).
---------------------------------------------------------------------------
    Specific categories of health care and social service 
workers suffer especially high risk of workplace violence. 
While the overall rate of workplace assault-related injuries 
for general industry workers was 4 per 10,000 in 2017, the 
workplace violence injury rate per 10,000 for licensed 
practical nurses was 11.8, registered nurses 13.6, social 
workers 16, nursing assistants 46.1, and psychiatric aides 
417.4.\7\
---------------------------------------------------------------------------
    \7\Bureau of Labor Statistics, Survey of Occupational Injuries and 
Illnesses (2017), https://www.bls.gov/web/osh/cd_r100.htm (Incidence 
rates of violence for nonfatal occupational injuries and illnesses 
involving days away from work).
---------------------------------------------------------------------------
    Studies have found between 19-30 percent of hospital 
workers report being physically assaulted at work, and 70 
percent of psychiatric hospital workers reported being 
assaulted during the past year.\8\
---------------------------------------------------------------------------
    \8\United States Government Accountability Office, Workplace Safety 
and Health: Additional Efforts Needed to Help Protect Health Care 
Workers from Workplace Violence 12 (2016), https://www.gao.gov/assets/
680/675858.pdf.
---------------------------------------------------------------------------
    Emergency rooms are also high-risk workplaces. According to 
a 2018 survey conducted by American College of Emergency 
Physicians, nearly half of emergency physicians polled reported 
being physically assaulted, with more than 60 percent of those 
occurring within the past year. Nearly 7 in 10 emergency 
physicians say emergency department violence has increased 
within the past 5 years.\9\
---------------------------------------------------------------------------
    \9\Letter from American College of Emergency Physicians President 
Vidor Friedman to Representative Joe Courtney (March 28, 2019), 
available at https://www.acep.org/globalassets/new-pdfs/advocacy/acep_-
workplace-violence-prevention-letter-of-support.pdf. 
---------------------------------------------------------------------------
    The Cleveland Clinic has been forced to take action against 
violence in their emergency rooms:

          When you visit the Cleveland Clinic emergency 
        department these days--whether as a patient, family 
        member or friend--a large sign directs you toward a 
        metal detector. An officer inspects all bags and then 
        instructs you to walk through the metal detector. In 
        some cases, a metal wand is used--even on patients who 
        come in on stretchers. Cleveland Clinic officials say 
        they confiscate thousands of weapons like knives, 
        pepper spray and guns each year. The metal detectors 
        were installed in response to what CEO Tom Mihaljevic 
        is calling an epidemic.\10\
---------------------------------------------------------------------------
    \10\Marlene Harris-Taylor, Facing Escalating Workplace Violence, 
Hospital Employees Have Had Enough, National Public Radio (Apr. 8, 
2019, 4:26 PM), https://www.npr.org/sections/health-shots/2019/04/08/
709470502/facing-escalating-workplace-violence-hospitals-employees-
have-had-enough. 

    The problem of workplace violence against health care 
workers is getting worse. According to BLS statistics, from 
2008 to 2017, the incidence rate for injuries resulting from 
workplace violence in psychiatric and substance abuse hospitals 
increased by 158 percent and is now at the highest ever. The 
rate more than doubled in private hospitals and home health 
care services and increased 68 percent in nursing and 
residential care facilities, while the overall rate for private 
sector health care and social service workers went up 69 
percent over the same period.\11\
---------------------------------------------------------------------------
    \11\U.S. Department of Labor, Bureau of Labor Statistics, Survey of 
Occupational Injuries and Illnesses https://www.bls.gov/iif/oshwc/osh/
case/ostb2090.pdf, (2008), https://www.bls.gov/web/osh/cd_r8.htm, 2017, 
(Incidence rates of violence for nonfatal occupational injuries and 
illnesses involving days away from work.).
---------------------------------------------------------------------------
    Dr. Angelo McClain, Executive Director of the National 
Association of Social Workers, testified at the WP Subcommittee 
Hearing that social workers are also seeing increasing numbers 
of assaults:

          We are seeing more violence as there is more 
        substance use and more critical kind of situations we 
        are going into and we know with the opioid crisis, 
        child welfare removals have gone up 20 percent.
          So, it's just working in those environments there's 
        more opportunity or more tendency for to confront 
        violence situations.\12\
---------------------------------------------------------------------------
    \12\Caring for our Caregivers: Protecting Health Care and Social 
Service Workers from Workplace Violence, YouTube (Mar. 1, 2019), 
https://www.youtube.com/watch?v=3B9eMBSBKm0 (Question and answer 
between Rep. Courtney and McClain at 1:21:37).

    Workplace violence against this nation's caregivers not 
only causes serious physical injuries and sometimes death, but 
it can also lead to post-traumatic stress disorder (PTSD). 
Patricia Moon Updike, who testified at the WP Subcommittee 
Hearing, was assaulted by a patient in 2015 while working as a 
nurse in the Behavioral Health Division of Milwaukee County in 
the Child and Adolescent Treatment Unit. Not only did she 
---------------------------------------------------------------------------
suffer serious physical injuries, but also PTSD. She testified:

          I woke up after surgery with a large collar around my 
        neck and I was fortunate. I was in pain. I was bruised 
        and I was in shock, but my trachea was intact and I was 
        breathing on my own.
          Two days later the nightmares started. I couldn't 
        sleep. I figured it would pass. However, this was a 
        different kind of feeling than I had ever experienced 
        before. As time passed, I became more scared of people 
        and children being unpredictable.
          Since this injury in 2015, I have been diagnosed with 
        moderate to severe PTSD, moderate anxiety, insomnia, 
        depressive disorder and social phobia related to this 
        incident. I suffer from terrible memory problems. I 
        cannot wear a seat belt properly, it comes too close to 
        my neck and I have to wear it around my waist. I have 
        not been to a mall, a concert or a sporting event since 
        this assault due to my fear of crowds.\13\
---------------------------------------------------------------------------
    \13\Caring for our Caregivers: Protecting Health Care and Social 
Service Workers from Workplace Violence, Hearing Before the Subcomm. on 
Workforce Protections of the H. Comm. on Educ. and Labor, 116th Cong. 
(2019) (Written testimony of Patricia Moon-Updike at 3) [Hereinafter 
Moon-Updike Testimony].
---------------------------------------------------------------------------

Workplace Violence is More Severe in State and Local Government Health 
        Care and Social Service Settings

    In 2017, state government health care and social service 
workers were almost 9 times more likely to be injured by an 
assault than private sector health care workers (128.9 vs. 14.7 
per 10,000 workers). Each year, nearly 7 percent of psychiatric 
aides employed in state and local government mental health 
facilities experienced violence-related injuries causing them 
to lose time from work. State mental health and substance abuse 
social workers experience extraordinarily high rates of 
assault-related injury--278.7 per 10,000 workers in 2017. 
Psychiatric aides experienced injuries caused by violence at a 
rate of 693.4 per 10,000 workers; psychiatric technicians at 
591.4 per 10,000 workers; nursing, psychiatric and home health 
aides at 339.9 per 10,000 workers; health care support 
occupations at 256.0 per 10,000 workers; and nursing assistants 
at 155.2 per 10,000 workers.\14\
---------------------------------------------------------------------------
    \14\Bureau of Labor Statistics, Survey of Occupational Injuries and 
Illnesses (2017), generated from online database of ``Nonfatal cases 
involving days away from work: selected characteristics (2011 
forward),'' https://www.bls.gov/iif/data.htm. See attached Appendix A 
to this Committee Report.
---------------------------------------------------------------------------
    In 24 states, nearly 8 million employees are employed by 
state and local governments\15\, but these public employees are 
not covered by Federal or state OSHA plans, and thus have no 
legal right to a safe workplace.\16\ Under Section 3(b) of the 
OSH Act, OSHA may not enforce its standards with respect to 
state and local government employers in those 24 states.\17\
---------------------------------------------------------------------------
    \15\Death on the Job: The Toll of Neglect, AFL-CIO, 23, (2019), 
https://aflcio.org/reports/death-job-toll-neglect-2019.
    \16\Alabama, Arkansas, Colorado, Delaware, District of Columbia, 
Florida, Georgia, Idaho, Kansas, Louisiana, Massachusetts, Mississippi, 
Missouri, Montana, Nebraska, New Hampshire, North Dakota, Ohio, 
Oklahoma, Pennsylvania, Rhode Island, South Dakota, Texas, West 
Virginia, Wisconsin.
    \17\29 U.S.C. Sec. 652 (5) states: ``The term `employer' means a 
person engaged in a business affecting commerce who has employees, but 
does not include the United States (not including the United States 
Postal Service) or any State or political subdivision of a State.''
---------------------------------------------------------------------------
    In the WP Subcommittee Hearing, Patricia Moon-Updike 
testified about the predicament that public employees face 
without OSHA protections:

          There was no state agency responsible for protecting 
        workers at my facility and that is still the case 
        today. Workers were and are still getting hurt--and no 
        one knows about it.
          There are no safety protocols in place and the 
        employer has no incentive to implement them, or even 
        record assaults. How can health care employees trust 
        that a self-governing, bottom-line obsessed, patient 
        satisfaction-oriented facility has the employees' lives 
        as a priority if not directly being overseen by OSHA to 
        do so?
          All workers deserve workplace safety protection. 
        State and local public employees do some very difficult 
        and dangerous jobs, including working in jails and 
        prisons and caring for forensic patients (persons found 
        unfit to be tried for a crime or found not guilty due 
        to mental illness) in state psychiatric hospitals. 
        These workers face risks that are generally not found 
        in the private sector. They deserve protection from 
        OSHA.\18\
---------------------------------------------------------------------------
    \18\Caring for our Caregivers: Protecting Health Care and Social 
Service Workers from Workplace Violence, Hearing Before the Subcomm. on 
Workforce Protections of the H. Comm. on Educ. and Labor, 116th Cong. 
(2019) (Forthcoming Moon-Updike response to a question for the record 
from Rep. Alma Adams).
---------------------------------------------------------------------------

Episodes of Workplace Violence of all Categories are Underreported and 
        Workers Fear Retaliation for Reporting

    Despite the BLS data showing a high rate of injuries to 
health care and social service workers from workplace violence, 
studies indicate these numbers are likely to represent a 
significant undercount of injuries resulting from assaults. 
According to the GAO, estimates of the percentage of injury 
cases that are formally reported ranged from 7 to 42 percent. 
Only 30 percent of nurses report incidents of workplace 
violence after being assaulted;\19\ among emergency department 
nurses, the reporting rate is 35 percent\20\ and among 
emergency department physicians, the reporting rate is only 26 
percent.\21\ Other reports have found overall underreporting as 
high as 88 percent.\22\
---------------------------------------------------------------------------
    \19\Judith E. Arnetz, et. al., Underreporting of Workplace 
Violence: Comparison of Self-Report and Actual Documentation of 
Hospital Incidents, 63 Workplace Health and Safety 207 (2015).
    \20\Emergency Nurses Association Institute for Emergency Nursing 
Research, Emergency Department Violence Surveillance Study, 25, 
November 2011.
    \21\M. Benham, et al., Violence in the Emergency Department: A 
National Survey of Emergency Medicine Residents and Attending 
Physicians, 40 Journal of Emergency Medicine 565, 568 (2011).
    \22\Judith E. Arnetz, et. al., Underreporting of Workplace 
Violence: Comparison of Self-Report and Actual Documentation of 
Hospital Incidents, 63 Workplace Health and Safety 208 (2015).
---------------------------------------------------------------------------
    Underreporting is due in part to thinking that enduring 
violence is ``part of the job.''\23\ Moreover, workers often do 
not report injuries to employers because the reporting 
mechanism is burdensome, management discourages reporting, or 
they fear they will be blamed for an altercation involving a 
patient or resident. Other reasons include inconvenience, fear 
of retaliation, unclear reporting policies, and expectation 
that nothing will be done.\24\ Sometimes workers are uncertain 
what constitutes violence, because they often believe that 
their assailants are not responsible for their actions due to 
medical conditions. Some employers discourage reporting if they 
believe it will increase workers' compensation insurance 
rates.\25\
---------------------------------------------------------------------------
    \23\Sentinel Event Alert, Physical and Verbal Violence Against 
Health Care Workers, 2 (2018), https://www.jointcommission.org/assets/
1/18/SEA_59_Workplace_violence_4_13_18_FINAL.pdf.
    \24\Karen Gabel Speroni, et al., Incidence and Cost of Nurse 
Workplace Violence Perpetrated by Hospital Patients or Patient 
Visitors, 41 Journal of Emergency Nursing 218, 227 (2014).
    \25\Darryl Beard and Michelle Conley, Operation Safe Workplace: A 
Multidisciplinary Approach to Workplace Violence 11 (2017), https://
www.jointcommission.org/assets/1/6/Aria_Workplace_Safety.pdf.
---------------------------------------------------------------------------
    Ms. Moon-Updike confirmed these problems in her testimony 
at the WP Subcommittee Hearing:

          I don't know how many of the general public are aware 
        that there is a code of silence in the nursing 
        profession that you don't report. It is highly 
        underreported the injuries in the nursing profession. 
        It is, and excuse my vernacular, but it is pretty much 
        suck it up and take it.\26\

    \26\Caring for our Caregivers: Protecting Health Care and Social 
Service Workers from Workplace Violence, YouTube (Mar. 1, 2019), 
https://www.youtube.com/watch?v=3B9eMBSBKm0 (Question and answer 
between Rep. Jayapal and Moon-Updike at 00:54:46).
---------------------------------------------------------------------------
    Some nurses describe being blamed for altercations. 
According to an interview with Michelle Mahon, RN, a Nursing 
Practice Representative of National Nurses United:

          ``What happens if they do report it?'' she says. ``In 
        some cases, unfortunately, they are treated as if they 
        are the ones who don't know how to do their job. Or 
        that it's their fault that this happened.''
          ``There's a lot of focus on de-escalation 
        techniques,'' Mahon adds. ``Those are helpful tools, 
        but oftentimes they are used to blame workers.''\27\

    \27\Marlene Harris-Taylor, Facing Escalating Workplace Violence, 
Hospital Employees Have Had Enough, National Public Radio (Apr. 8, 
2019), https://www.npr.org/sections/health-shots/2019/04/08/709470502/
facing-escalating-workplace-violence-hospitals-employees-have-had-
enough.
---------------------------------------------------------------------------
    And Ms. Moon-Updike confirmed the problem of retaliation in 
her testimony:

          ``it is not--it is not very well tolerated to report 
        when you have been injured because often it falls back 
        onto you as it was your fault for not being careful 
        enough or using a protocol.''\28\
---------------------------------------------------------------------------
    \28\Caring for our Caregivers: Protecting Health Care and Social 
Service Workers from Workplace Violence, YouTube (Mar. 1, 2019), 
https://www.youtube.com/watch?v=3B9eMBSBKm0 (Question and answer 
between Rep. Jayapal and Moon-Updike at 00:55:22).

    The violent incident log, required under H.R. 1309, would 
address the problem of underreporting. As Dr. Jane Lipscomb 
stated in response to a Question for the Record following the 
---------------------------------------------------------------------------
WP Subcommittee Hearing:

          ``A required violent incident log would reduce the 
        well-recognized problem of underreporting of incidents 
        of workplace violence. A more complete reporting and 
        analysis of incidents of workplace violence would allow 
        health care organizations to understand the magnitude 
        of the problem in their workplace and identify risk 
        factors for violence that could then be prevented by 
        the implementation of appropriate hazard 
        controls.''\29\
---------------------------------------------------------------------------
    \29\Caring for our Caregivers: Protecting Health Care and Social 
Service Workers from Workplace Violence, Hearing Before the Subcomm. on 
Workforce Protections of the H. Comm. on Educ. and Labor, 116th Cong. 
(2019) (Forthcoming Lipscomb response to a question for the record from 
Rep. Alma Adams.).

Workplace Violence in Health Care and Social Service Settings is 
        Predictable and Preventable

    Health care and social service workers face an elevated 
risk of work-related assaults, which results primarily from the 
violent behavior of their patients, clients, residents (or 
family members accompanying them). While no specific diagnosis 
or type of patient predicts specific incidents of future 
violence, studies consistently demonstrate that inpatient and 
acute psychiatric services, geriatric long-term care settings, 
high volume urban emergency departments, and residential and 
day social services present the highest risks. Pain, 
devastating prognoses, long waiting times, unfamiliar 
surroundings, altered mental status associated with dementia, 
delirium or mind-and mood-altering medications and drugs, and 
disease progression can cause agitation and violent behaviors 
in patients, clients, or residents.
    Workplace violence traditionally falls into four types: 
Type 1 involves criminal intent, such as an assault in 
connection with a robbery; Type 2 involves clients, patients, 
or residents; Type 3 involves a coworker; and Type 4 is 
perpetrated by someone who knows or has a personal relationship 
with an employee at a workplace.\30\ OSHA's Guidelines and a 
number of academic studies have identified workplace violence 
prevention plans as an effective tool to reduce or mitigate 
injuries from workplace violence--especially violence involving 
clients, patients or residents. Unlike some forms of violence, 
Type 2 violence can be anticipated and managed.
---------------------------------------------------------------------------
    \30\Occupational Safety and Health Administration, U.S. Department 
of Labor Directive CPL 02-01-058, Enforcement Procedures and Scheduling 
for Occupational Exposure to Workplace Violence (2017), available at 
https://www.osha.gov/OshDoc/Directive_pdf/CPL_02-01-058.pdf.
---------------------------------------------------------------------------
    A workplace violence prevention plan requires risk 
assessment, implementation of controls, training, 
recordkeeping, and program evaluation. Controls may include 
engineering controls or administrative (work practice) 
controls. Engineering controls may include enhanced security 
and alarms, panic buttons, better exit routes, and better 
lighting. Administrative, or work practice controls, affect the 
way employees perform their job responsibilities and may 
include such measures as reducing crowding and waiting time, 
additional staffing, and implementing emergency response 
procedures.
    While it is not the role of OSHA to dictate standards of 
care in health care settings, the voluntary OSHA Guidelines 
recommend the use of Trauma Informed Care (TIC) as a treatment 
technique and work practice control that has reduced violence 
in psychiatric settings.\31\ TIC is an intervention that 
recognizes that a patient or client's history of trauma may 
impact their response to services.\32\
---------------------------------------------------------------------------
    \31\Id. at 7.
    \32\Substance Abuse and Mental Health Services Administration, 
Trauma-Informed Care in Behavioral Health Services xix (2014), https://
store.samhsa.gov/system/files/sma14-4816.pdf.
---------------------------------------------------------------------------
    Training may also help mitigate or prevent assaults. For 
example, training in de-escalation techniques has been shown to 
be effective.\33\
---------------------------------------------------------------------------
    \33\Judith E. Arnetz, et al., Preventing Patient-to-Worker Violence 
in Hospitals: Outcome of a Randomized Controlled Intervention, 59 
Journal of Occupational and Environmental Medicine 18 (2017), available 
at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5214512/pdf/nihms-
822608.pdf.
---------------------------------------------------------------------------
    The Joint Commission, which accredits health care 
institutions, recommends:

          After a review of all pertinent data relating to 
        workplace violence, develop evidence-based initiatives 
        and interventions (when possible) to prevent and 
        control workplace violence. Tailor specific 
        interventions to problems identified at the local 
        level.\34\
---------------------------------------------------------------------------
    \34\Sentinel Event Alert, Physical and Verbal Violence Against 
Health Care Workers 5 (2018), https://www.jointcommission.org/assets/1/
18/SEA_59_Workplace_violence_4_13_18_FINAL.pdf.

    Many of the Joint Commission's recommended measures are 
included in H.R. 1309. These include the implementation of 
engineering and administrative controls, worker training and 
program evaluation, reporting systems, incident investigations, 
and protection against retaliation for reporting incidents.
    Studies have shown that the measures in H.R. 1309 would 
significantly reduce assaults on health care and social service 
workers. Aria-Jefferson Health in Pennsylvania implemented many 
of the measures required by this standard and reduced violence-
related injuries by 55 percent over three years.\35\
---------------------------------------------------------------------------
    \35\Darryl Beard and Michelle Conley, Operation Safe Workplace: A 
Multidisciplinary Approach to Workplace Violence 3 (2017), https://
www.jointcommission.org/assets/1/6/Aria_Workplace_Safety.pdf.
---------------------------------------------------------------------------
    A recent randomized controlled trial involving seven 
hospitals in the Wayne State system compared 21 health care 
facility units that conducted workplace violence prevention 
techniques to units in 20 health care facility units that did 
not. The study found that six months post-intervention, 
incident rate ratios of violent events were significantly lower 
(more than a 50 percent reduction) on intervention units 
compared with controls. At the 24 month-follow up, the risk for 
violence-related injury was significantly lower (more than a 60 
percent reduction) on intervention units compared with 
controls.\36\ The types of intervention included a combination 
of environmental, administrative, and behavioral strategies. 
The intervention strategies used across study units were the 
exact type of interventions contained in OSHA's Guidelines and 
that would be required of employers by the OSHA standard 
required by H.R. 1309.
---------------------------------------------------------------------------
    \36\Judith E. Arnetz, et al., Preventing Patient-to-Worker Violence 
in Hospitals: Outcome of a Randomized Controlled Intervention, 59 
Journal of Occupational and Environmental Medicine 18 (2017), available 
at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5214512/pdf/nihms-
822608.pdf.
---------------------------------------------------------------------------
    Dr. McClain testified at the WP Subcommittee Hearing that 
H.R. 1309 would also improve safety for social service workers 
who work in the field, and it would not require residents to 
make changes to their homes:

          Measures such as ``buddy systems,'' GPS tracking 
        systems, escorts and pre-visit assessments to identify 
        and address potential threats would be required to be 
        instituted.
          We cannot expect clients to make changes to their 
        home. That is why it is essential that workplaces have 
        in place effective home visit safety measures such as 
        those listed above.\37\
---------------------------------------------------------------------------
    \37\Caring for our Caregivers: Protecting Health Care and Social 
Service Workers from Workplace Violence, Hearing Before the Subcomm. on 
Workforce Protections of the H. Comm. on Educ. and Labor, 116th Cong. 
(2019) (Forthcoming McClain response to a question for the record from 
Rep. Alma Adams.).

    Studies have shown that ensuring the safety of health care 
and social service workers also benefits patients and clients. 
---------------------------------------------------------------------------
Dr. Lipscomb testified at the WP Subcommittee Hearing that:

          This bill and an OSHA standard would also protect and 
        promote patient safety by reducing the risk of violence 
        from patients and visitors who not only assault 
        workers, but also other patients. Health care worker 
        health and safety and patient safety are inextricably 
        linked. When patient violence is left unchecked, 
        patients also suffer the consequences of such assaults 
        both in terms of increased risk of injury and when care 
        is compromised because health care workers become 
        injured and can no longer provide high quality 
        care.\38\
---------------------------------------------------------------------------
    \38\Caring for our Caregivers: Protecting Health Care and Social 
Service Workers from Workplace Violence, Hearing Before the Subcomm. on 
Workforce Protections of the H. Comm. on Educ. and Labor, 116th Cong. 
(2019) (Forthcoming Lipscomb response to a question for the record from 
Rep. Alma Adams.).

    Patient safety was also enhanced by interventions made to 
protect workers from workplace violence that resulted in a 28 
percent reduction in the use of patient restraints.\39\
---------------------------------------------------------------------------
    \39\Yana Dilman, EB72: Code Green for Workplace Violence, American 
Nurse Today, February 2017 Vol. 12 No. 2). https://
www.americannursetoday.com/code-green-prevents-workplace-violence/
---------------------------------------------------------------------------
    And, as Dr. McClain noted in his testimony at the WP 
Subcommittee Hearing:

          Further justification for H.R. 1309 is the fact that 
        it is essential that settings that provide social 
        services be healing environments. When a client harms a 
        social worker or other professional in these 
        environments, it is traumatizing for the client, not 
        just the person they harmed. It disrupts the 
        therapeutic process and can set back progress by months 
        if not years. Clients witnessing violence are also 
        traumatized, which impedes their progress. Through 
        common sense safety measures, workplaces can reduce or 
        eliminate this primary and secondary trauma, resulting 
        in better outcomes not just for clients but also for 
        the larger community.\40\
---------------------------------------------------------------------------
    \40\Caring for our Caregivers: Protecting Health Care and Social 
Service Workers from Workplace Violence, Hearing Before the Subcomm. on 
Workforce Protections of the H. Comm. on Educ. and Labor, 116th Cong. 
(2019) (Forthcoming McClain response to a question for the record from 
Rep. Alma Adams.).

    Finally, H.R. 1309 does not require OSHA to issue a ``one-
size-fits-all'' standard that prescribes every step that every 
employer must take. In fact, it is just the opposite. The 
interim and final standards will be ``program standards,'' 
which set forth the basic elements of a workplace violence 
prevention program. The employer will be required to tailor 
their violence prevention plan according to the size and type 
of the operation, the specific risks presented, and the types 
of interventions that are needed to protect workers.

OSHA Has Developed Authoritative Voluntary Guidelines as Part of a 
        Program of Compliance Assistance

    For over 20 years, OSHA has conducted compliance assistance 
activities to assist employers in reducing workplace violence--
including the dissemination of best practices. In 1996, OSHA 
first issued its Guidelines which were updated in 2004 and 
again in 2015. However, OSHA notes that these voluntary 
guidelines are ``advisory in nature and informational in 
content.'' Nonetheless, these are frequently cited by industry 
and safety professionals, because the Guidelines are:

          based on industry best practices and feedback from 
        stakeholders and provide recommendations for developing 
        policies and procedures to eliminate or reduce 
        workplace violence in a range of healthcare and social 
        service settings . . . and incorporate the latest and 
        most effective ways to reduce the risk of violence in 
        the workplace.\41\
---------------------------------------------------------------------------
    \41\Occupational Safety and Health Administration, Guidelines for 
Preventing Workplace Violence for Health Care and Social Service 
Workers 1 (2016), https://www.osha.gov/Publications/osha3148.pdf.

    These Guidelines are the foundation for the violence 
prevention standard required in H.R. 1309.

OSHA's Efforts to Prevent Workplace Violence Have Been Limited by 
        Reliance on the General Duty Clause, Instead of a Specific 
        Standard

    When OSHA does not have a standard that specifically 
addresses a recognized hazard, it must use the General Duty 
Clause (GDC) of the OSH Act to enforce safe working conditions. 
The General Duty Clause states that each employer:

          shall furnish to each of his employees employment and 
        a place of employment which are free from recognized 
        hazards that are causing or are likely to cause death 
        or serious physical harm to his employees.\42\
---------------------------------------------------------------------------
    \42\29 U.S.C. Sec. 654(a)(1).

    In general, the GDC is poorly suited to the enforcement of 
protections regarding workplace violence because its use is 
legally burdensome and faces repeated legal attack by employers 
who want to categorize workplace violence as a random, 
unpreventable act rather than a recognized hazard that can be 
prevented or mitigated. The GDC can only be used if OSHA can 
show in each separate instance that there is a serious 
recognized hazard and there are feasible means of abatement. By 
comparison, an OSHA standard delineates mandatory compliance 
elements. Because of the legal burdens associated with use of 
the GDC, only a small number of OSHA inspections regarding 
workplace violence result in citations.
    OSHA implemented a 3-year National Emphasis Program (NEP) 
in 2012 that targeted nursing and residential care facilities 
and included workplace violence. Inspections of health care 
employers related to workplace violence increased from 11 
inspections per year in 2010 to 86 inspections in 2014.\43\ 
OSHA also issued a workplace violence compliance directive in 
2011, which was updated in January 2017,\44\ to assist OSHA 
inspectors in inspecting worksites and building a case under 
the GDC. From 1991 through October 2014, OSHA issued 18 general 
duty clause citations to health care employers for failing to 
address workplace violence. These citations were issued in 
approximately five percent of the 344 workplace violence 
inspections of health care employers that were conducted from 
1991 to April 2015. In practice, the GDC is used only after a 
worker has been injured or killed; in all 18 of the cases where 
OSHA issued citations, health care workers had been injured or 
killed by patients, clients, or residents.
---------------------------------------------------------------------------
    \43\United States Government Accountability Office, Workplace 
Safety and Health: Additional Efforts Needed to Help Protect Health 
Care Workers from Workplace Violence (2016), https://www.gao.gov/
assets/680/675858.pdf.
    \44\Occupational Safety and Health Administration, U.S. Department 
of Labor Directive CPL 02-01-058, Enforcement Procedures and Scheduling 
for Occupational Exposure to Workplace Violence (2017), available at 
https://www.osha.gov/OshDoc/Directive_pdf/CPL_02-01-058.pdf.
---------------------------------------------------------------------------
    As noted above, the use of the GDC is under constant legal 
threat. In the Integra Health Management case, which came 
before the Occupational Safety and Health Review Commission 
(OSHRC),\45\ a community health worker was stabbed to death by 
a client outside of his residence in 2012. OSHA cited Integra 
using the General Duty Clause and fined the company $10,500. 
Integra appealed the citation on the grounds that the ``hazard 
of being assaulted by [a client] with a history of violent 
behavior'' is not a recognized hazard and that abatement of 
that hazard was not feasible.\46\ The U.S. Chamber of Commerce 
argued that OSHA should not be able to use the GDC in 
combination with the OSHA Guidelines ``as a substitute for 
[its] obligation to enforce the Act principally by promulgating 
specific standards under the Act's rulemaking provisions.''\47\ 
Although OSHRC sustained the citations against Integra, 
continued attacks on use of the GDC can be expected until OSHA 
adopts a specific violence prevention standard.
---------------------------------------------------------------------------
    \45\Integra Health Management, Inc., 2015 OSAHRC LEXIS 46 (No.13-
1124, 2015), available at https://www.oshrc.gov/assets/1/18/
Integra_Health_Management,_Inc._Docket_13-1124_Combined _post.pdf?8328.
    \46\Brief of Respondent at 8, Integra Health Management, Inc., 2015 
OSAHRC LEXIS 46 (No.13-1124, 2015), available at https://www.oshrc.gov/
assets/1/6/RespondentsPost-HearingBrief.pdf.
    \47\Brief for Integra Health Management, Inc., as Amicus Curiae 
Chamber of Commerce of the United States of America supporting 
Respondent, 2015 OSAHRC LEXIS 46 (No.13-1124, 2015), available at 
https://www.oshrc.gov/assets/1/6/
Brief_of_Amicus_Brief_of_Chamber_of_Commerce
_of_USA_in_Support_of_Respondent_Integra 
_Health_Management_Redacted.pdf.
---------------------------------------------------------------------------

OSHA's Efforts to Promulgate a Workplace Violence Prevention Standard 
        Have Been Halting and Inconsistent

    Following the issuance of the 2016 GAO study and the 
receipt of two petitions for a workplace violence standard, the 
Obama Administration added workplace violence to the regulatory 
agenda and issued a Request for Information to solicit 
information on the content of a potential standard to prevent 
workplace violence in health care and social assistance 
settings.\48\ OSHA held a stakeholder meeting on January 10, 
2017, at which the Assistant Secretary granted the petitions 
for rulemaking and announced that the agency would pursue a 
workplace violence prevention standard.
---------------------------------------------------------------------------
    \48\Request for Information, Prevention of Workplace Violation in 
Healthcare and Social Assistance, 81 Fed. Reg. 88147 (Dec. 7, 2016).
---------------------------------------------------------------------------
    The Trump Administration's first Regulatory Agenda 
relegated work on the workplace violence prevention standard to 
the ``Long-Term Agenda'' for a year, but returned it to OSHA's 
active Regulatory Agenda in May 2018. Over the past two-and- 
one-half years, OSHA's sole visible effort was a statement in 
the Regulatory Agenda of its the intent to hold a Small 
Business Regulatory Enforcement Fairness Act (SBREFA) panel. 
The panel was originally set to meet in January 2019, then OSHA 
postponed the meeting to March 2019, and OSHA postponed it 
again to October 2019 but has not yet been noticed. However, 
the SBREFA small business review panel comes at the earliest 
stage of the rulemaking process and does not signify that the 
issuance of a proposed standard is foreseeable in the near 
future.
    OSHA has also been constrained in prioritizing a workplace 
violence prevention standard since 2017 due to a presidential 
mandate to focus on deregulatory efforts. The Trump 
Administration's Executive Order ``Reducing Regulation and 
Controlling Regulatory Costs'' requires that for every new 
regulation an agency adopts, two regulations of the same cost 
must be eliminated.\49\
---------------------------------------------------------------------------
    \49\Exec. Order No. 13,7871, 83 Fed. Reg. 9339 (Jan. 30, 2017).
---------------------------------------------------------------------------

Voluntary Guidelines, Compliance Assistance and Enforcement Through the 
        OSH Act's General Duty Clause Are Not Sufficient to Protect 
        Workers

    Although OSHA has been conducting compliance assistance 
activities for over 20 years, as noted above, and revised its 
Guidelines in 2015, these activities have not been sufficient 
to adequately protect workers. Not only are violence-related 
injury rates increasing, but as Dr. Jane Lipscomb testified at 
the WP Subcommittee Hearing:

          [V]oluntary guidelines such as those that were first 
        published by OSHA in 1996 and updated in 2015, do not 
        protect the vast majority of employees, because they 
        fail to incentivize employers to act voluntarily to 
        address this hazard. I can attest to that fact because 
        the vast majority of health care workers who I have 
        spoken with report that they do not have a workplace 
        violence prevention plan or that they have a paper plan 
        that does little to nothing to protect them from the 
        ongoing risk of violence.\50\
---------------------------------------------------------------------------
    \50\Caring for our Caregivers: Protecting Health Care and Social 
Service Workers from Workplace Violence, Hearing Before the Subcomm. on 
Workforce Protections of the H. Comm. on Educ. and Labor, 116th Cong. 
(2019) (Written Testimony of Jane Lipscomb at 1) [Hereinafter Lipscomb 
Testimony].

    Without a legally enforceable OSHA standard, important 
elements such as incident investigations may not happen. 
Patricia Moon-Updike described this situation in a post-WP 
---------------------------------------------------------------------------
Subcommittee Hearing submission:

          I am not aware of any investigation of my assault. I 
        was only asked for my account of events for Workers 
        Compensation management purposes. I have no knowledge 
        of any investigations of incidents of workplace 
        violence with or without workers' participation or 
        review of the findings. Wisconsin's Act 10, which 
        placed limits on public employees' collective 
        bargaining rights also precluded the union from 
        participating in an investigation.\51\
---------------------------------------------------------------------------
    \51\Caring for our Caregivers: Protecting Health Care and Social 
Service Workers from Workplace Violence, Hearing Before the Subcomm. on 
Workforce Protections of the H. Comm. on Educ. and Labor, 116th Cong. 
(2019) (Forthcoming Moon-Updike response to a question for the record 
by Rep. Alma Adams).
---------------------------------------------------------------------------

State Legislative and Regulatory Activity

    Ten states--California, Connecticut, Illinois, Maine, 
Maryland, Nevada, New Jersey, New York, Oregon, and 
Washington--have some form of laws or regulations covering 
workplace violence in health care. Nevada recently passed a 
comprehensive workplace violence law covering health care 
workers that will come into full effect in 2021.\52\ None of 
the states cover social service workers with the exceptions of 
Illinois (covers clinical social workers who work inside a 
health care facility) and New York (covers public employees, 
including those in health care and social services, but not 
private sector employees).\53\ Some laws lack enforcement 
mechanisms. Only four of the nine (California, Washington, 
Nevada, and New York) have enforcement mechanisms that operate 
through their state OSHA programs where workers can file 
complaints and receive an inspection. The Illinois Health Care 
Violence Prevention Act, which is administered by the Illinois 
Department of Public Health, requires health care providers (as 
well as the Departments of Corrections and Juvenile Justice) to 
develop a workplace violence prevention program modeled on 
OSHA's Guidelines, but the law does not address inspections or 
consequences for non-compliance.\54\
---------------------------------------------------------------------------
    \52\Assembly Bill 348, 80th Leg., Reg. Sess. (Nev. 2019), available 
at https://www.leg.state.nv.us/App/NELIS/REL/80th2019/Bill/6646/Text.
    \53\N.Y. Comp. Codes R. & Regs. tit. 12 Sec. 800.6 (2006).
    \54\H.B. 4100 of the 100th General Assembly [Public Act 100-1051] 
(Ill. 2018).
---------------------------------------------------------------------------

H.R. 1309 Provides for Robust Public Input into the Rulemaking Process

    Input by workers, employers, and experts on the subject of 
workplace violence is of vital importance in order to issue an 
effective and feasible OSHA standard. H.R. 1309 requires all of 
the federal rulemaking requirements, including full notice and 
comment, for the final workplace violence standard that must be 
issued within 42 months of the date of enactment.
    Given the rising rates of workplace violence and the need 
for urgent action to stem injuries to workers, H.R. 1309 
requires OSHA to issue an interim final standard within a year, 
and the bill as introduced waived OSHA's procedural 
requirements for the interim final standard only. H.R. 1309 was 
criticized during the legislative hearing for not allowing 
sufficient public input prior to issuance of the interim final 
standard. To address that concern, during the markup of H.R. 
1309, the Committee adopted by voice vote an amendment that 
would add a 30-day comment period prior to issuance of the 
interim final standard.
    Since there has already been considerable public comment on 
a potential workplace violence standard, advancing to an 
interim final standard would reflect consensus in the industry. 
Dr. Lipscomb noted in her testimony at the WP Subcommittee 
Hearing:

          OSHA has already had a request for information around 
        their plan to develop a workplace violence prevention 
        standard. So there certainly was the opportunity in 
        there. I was part of both that hearing and public 
        meeting so there has been input that has already been 
        provided. And there has been input from stakeholders 
        all around the country around these other 9 actual laws 
        and, as I said, experts in health care safety and 
        patient safety have all written documents that 
        recommend pretty much the same measures that are 
        described in this bill.
          So, I completely disagree that there hasn't been an 
        opportunity for stakeholder input. In fact, I think 
        there is a consensus in the industry on what is 
        needed.\55\
---------------------------------------------------------------------------
    \55\Caring for our Caregivers: Protecting Health Care and Social 
Service Workers from Workplace Violence, YouTube (Mar. 1, 2019), 
https://www.youtube.com/watch?v=3B9eMBSBKm0 (Question and answer 
between Chairman Scott and Lipscomb at 01:07:22).
---------------------------------------------------------------------------

Absent Congressionally Mandated Deadlines, OSHA Standards Often Take 
        Decades to be Issued

    Due to the high number and rate of serious injuries caused 
by workplace violence and the ready availability of effective 
and feasible means to prevent or mitigate these assaults, H.R. 
1309 sets deadlines for OSHA to protect workers.
    In 2012, GAO issued a report regarding the protracted 
length of time it takes OSHA to issue a standard. It found 
that:

          Between 1981 and 2010, the time it took the 
        Department of Labor's Occupational Safety and Health 
        Administration (OSHA) to develop and issue safety and 
        health standards ranged widely, from 15 months to 19 
        years, and averaged more than 7 years.\56\
---------------------------------------------------------------------------
    \56\United States Government Accountability Office, Workplace 
Safety and Health: Multiple Challenges Lengthen OSHA's Standard Setting 
(2012), https://www.gao.gov/assets/590/589825.pdf.

    In order to issue a standard, OSHA must complete multiple 
steps that, depending on resources and competing priorities, 
can be quite lengthy. These include:
           Request for Information (RFI) and/or an 
        Advance Notice of Proposed Rulemaking (ANPRM): While 
        not mandatory, OSHA often issues an RFI and/or an ANPRM 
        in order to gather information that may be needed for a 
        proposal, or to decide whether a standard is needed. 
        Comment periods usually last several months, followed 
        by OSHA's analysis of the results. OSHA issued an RFI 
        and held a stakeholder meeting in January 2017 on the 
        workplace violence standard.
           Small Business Regulatory Enforcement 
        Fairness Act (SBREFA) Panel: The earliest major step in 
        the regulatory process is a review of the impact of a 
        regulation on small businesses required by SBREFA. 
        ``Small Entity Representatives'' are chosen to 
        participate in panels describing the possible impact of 
        a new OSHA standard. The findings are then compiled 
        into a report with recommendations that are considered 
        as the agency develops the regulatory proposal. It 
        requires six months from initiation of the SBREFA 
        process to completion of the final report, although 
        several months to a year are generally needed to 
        compile the data needed to initiate the process.
           Proposed Standard: OSHA must issue a 
        proposed standard that will undergo up to three months 
        of review by the Office of Management and Budget's 
        Office of Intergovernmental and Regulatory Affairs 
        (OIRA). The proposal contains a draft regulatory text, 
        suggested alternatives, and a Preliminary Regulatory 
        Flexibility Analysis (RFA) that explains the costs and 
        benefits of that rule. The RFA contains an extensive 
        justification of the economic and technical feasibility 
        of the standard and the presentation of regulatory 
        alternatives for consideration. It often takes OSHA 
        several years to move from SBREFA to a proposed rule.
           Hearings and Comment Period: Following the 
        issuance of the proposal, OSHA usually provides a 60-90 
        day written comment period, followed by public 
        hearings, which can last from a few days to several 
        weeks. Another written comment period, generally 60-90 
        days, follows the hearings.
           Final Standard: Following the completion of 
        the hearing and public comment periods, OSHA is 
        required to analyze and respond to each of the comments 
        on the proposal received during the public comment 
        periods and hearings, and based on that input, make 
        appropriate changes in the regulation and develop a 
        Final Regulatory Flexibility Analysis which is again 
        submitted to OIRA for a three-month review before the 
        final standard is issued. It often takes several years 
        to move from the proposal to the final standard.
    While all the above cited requirements would be in effect 
for the final standard, in order for health care and social 
service workers to receive timely protection against workplace 
violence, the interim final standard would require a 30 day 
comment period but would suspend these other requirements.
    Recent trends show that GAO's assessment from 2012 
underestimates the average time it now takes for OSHA to issue 
new safety and health standards. Set forth below are recent 
OSHA standards and the time required to finalize each standard.
           Beryllium (18 years): OSHA issued its final 
        Beryllium standard in January 2017\57\ after beginning 
        the most recent rulemaking process in 1999. This was 
        OSHA's second attempt to update its 1971 beryllium 
        standard. OSHA first issued a proposal to update its 
        beryllium standard in 1975, but the standard was never 
        completed.
---------------------------------------------------------------------------
    \57\29 C.F.R. Sec. 1910.1024 (2017), 29 C.F.R. 1926.1124 (2018), 
and 29 C.F.R. Sec. 1915.1024 (2017).
---------------------------------------------------------------------------
           Crystalline Silica (19 Years): OSHA issued 
        its final Silica standard in March 2016\58\ after the 
        issue was placed on the Regulatory Agenda in 1997. This 
        was OSHA's second attempt to update its silica 
        standard. The agency issued its first Advance Notice of 
        Proposed Rulemaking in 1975 but no proposal was ever 
        issued.
---------------------------------------------------------------------------
    \58\29 C.F.R. Sec. 1910.1053 (2016) and 29 C.F.R. Sec. 1926.1153 
(2016).
---------------------------------------------------------------------------
           Confined Spaces in Construction (22 years): 
        In May 2015, OSHA issued a Confined Spaces in 
        Construction standard\59\ after first committing to 
        issue this standard in 1993 and issuing a draft 
        proposed standard in 1994. This was OSHA's second 
        attempt to regulate confined spaces in the construction 
        industry. OSHA published an Advanced Notice of Proposed 
        Rulemaking in 1980, but that action was never 
        completed.
---------------------------------------------------------------------------
    \59\29 C.F.R. Sec. 1926.1200-1213 (2015).
---------------------------------------------------------------------------
           Walking Working Surfaces (14 years): In 
        2017, OSHA issued its revised Walking Working Surfaces 
        standard\60\ after initiating the regulatory process in 
        2003. This was OSHA's third attempt to update this 
        rule. OSHA's first proposed rule updating this standard 
        was issued in 1973 and a second proposed rule was 
        issued in 1990. Neither of these efforts were 
        completed.
---------------------------------------------------------------------------
    \60\29 C.F.R. Sec. 1910 Parts D and I (2016).
---------------------------------------------------------------------------

Completion of a Final Standard in 42 Months is Achievable

    OSHA should be able to finalize a workplace violence 
standard within the 42-month period that is set forth in H.R. 
1309. First, OSHA would not be starting from scratch. The main 
elements of this standard are contained in OSHA's Guidelines, 
which were revised in 2015. These Guidelines form the basis for 
many existing workplace violence programs in health care 
institutions today. Second, California has adopted a 
comprehensive workplace violence standard that contains most of 
the same elements contained in H.R. 1309. Third, OSHA would be 
building a final rule on the foundation set forth in the 
interim final standard, which must be issued within one year of 
enactment.

History of Congressionally Directed OSHA Rulemaking

    Congress has a long history of requiring OSHA to issue 
regulations to protect workers when the agency fails to act in 
a timely manner on its own. H.R. 1309 continues Congress's 
precedent of requiring OSHA to act promptly when faced with 
evidence that our nation's workers face grave dangers and delay 
will result in needless injury, illness, and death. For 
example:
           In 1986, as part of the Superfund Amendments 
        and Reauthorization Act of 1996 (SARA), Congress 
        required that OSHA issue an ``interim'' standard for 
        Hazardous Waste Operations and Emergency Response 
        within 60 days and a final standard within one year of 
        SARA's enactment. The standard was issued in 1989.\61\
---------------------------------------------------------------------------
    \61\Superfund Amendments and Reauthorization Act of 1986, Pub. L. 
No. 99-499, 126 a-f, 100 Stat. 1690-92.
---------------------------------------------------------------------------
           In 1990, as part of the Clean Air Act 
        Amendments, Congress required OSHA to issue the Process 
        Safety Management standard within one year. Congress 
        also included detailed directions on the content of the 
        standard. The standard was issued in 1992.\62\
---------------------------------------------------------------------------
    \62\1990 Clean Air Act Amendments, Pub. L. No. 101-549, 304, 104 
Stat. 2576-77.
---------------------------------------------------------------------------
           In 1991, Congress ordered OSHA to issue the 
        final Bloodborne Pathogens Standard by the end of 1991, 
        and stated that if that deadline was not met, the 
        previously published proposed standard would take 
        effect. The standard was issued in 1991.\63\
---------------------------------------------------------------------------
    \63\Departments of Labor, Health and Human Services and Education 
and Related Agencies Appropriations Act, Pub. L. No. 102-170, Sec. 100, 
105 Stat. 1113 (1991).
---------------------------------------------------------------------------
           In 1992, Congress required OSHA to issue the 
        Lead in Construction standard and required the new 
        standard to be ``as protective as'' the U.S. Department 
        of Housing and Urban Development's worker protection 
        guidelines for identification and abatement of lead-
        based paint in certain housing. OSHA was required to 
        issue an Interim Final Regulation for lead within 180 
        days. The standard was issued in 1993.\64\
---------------------------------------------------------------------------
    \64\Housing and Community Development Act of 1992, Pub. L. No. 102-
550, Sec. 402, 106 Stat. 3914.
---------------------------------------------------------------------------
           Finally, in 2000, Congress required OSHA to 
        issue an update to the Bloodborne Pathogens standard, 
        requiring safer syringes and sharps, ``without regard 
        to the procedural requirements applicable to 
        regulations promulgated under section 6(b) of the OSH 
        Act (29 U.S.C. 655(b)) or the procedural requirements 
        of chapter 5 of title 5, United States Code.''\65\ OSHA 
        was required to issue that standard within six months 
        of enactment. The standard was issued in 2001.
---------------------------------------------------------------------------
    \65\Needlestick Safety and Prevention Act, Pub. L. No. 106-430, 114 
Stat. 1901 (2000).
---------------------------------------------------------------------------

H.R. 1309 Provides Protection to Workers Employed by State and Local 
        Governments in Health Care and Social Service Settings Where 
        Federal OSHA Provides No Coverage

    As noted above, public sector health care and social 
service workers are almost nine times more likely to be injured 
by an assault than private sector health care workers, and in 
24 states these public sector workers lack OSHA protections. 
There is precedent for Congress to ensure the enforcement of 
OSHA standards affecting public sector health care workers in 
those states that do not provide OSHA coverage for public 
employees by amending the requirements for providers receiving 
Medicare funds.
    In 2003, Congress passed the Medicare Prescription Drug 
Improvement and Modernization Act, which included a requirement 
for public employers in the health care sector that receive 
Medicare funds, but are not covered by Federal or state OSHA, 
to comply with OSHA's bloodborne pathogens standard.\66\
---------------------------------------------------------------------------
    \66\The Medicare Prescription Drug, Improvement, and Modernization 
Act, Pub. L. No. 108-173, Sec. 947, 117 Stat. 2066, 2425 (2003).
---------------------------------------------------------------------------
    Section 947(a)(2) of that 2003 law states that providers 
that violate OSHA's bloodborne pathogens standard are ``not 
subject to termination of an agreement under this section,'' 
but are subject to a civil monetary penalty that is similar to 
the amount of civil penalties that may be imposed under the OSH 
Act for a violation of the Bloodborne Pathogens standard. The 
current maximum penalty for a serious violation of an OSHA 
standard is $13,260, although the average OSHA citation for a 
serious violation is approximately $3,000.
    H.R. 1309 mirrors that 2003 provision by requiring 
hospitals and skilled nursing facilities operated by state and 
local governments that receive Medicare funds, but are not 
covered by Federal OSHA or a state OSHA plan, to comply with 
OSHA's workplace violence prevention standard that will be 
issued by OSHA as mandated by H.R. 1309.

                      Section-by-Section Analysis


            Title I. Workplace Violence Prevention Standard


Section 101. Workplace violence prevention standard

    This section requires OSHA to issue a workplace violence 
prevention standard requiring employers within the health care 
and social service sectors to develop and implement a plan to 
protect their employees from workplace violence. OSHA shall 
carry this out in two stages: an interim final standard shall 
be issued within one year of enactment, and then a final 
standard shall be issued within 42 months of enactment. The 
interim final standard shall be based upon the OSHA Guidelines 
and the requirements set forth in this bill. A 30-day comment 
period will be provided before issuance of the interim final 
standard.

Section 102. Scope and application

    The interim and final standards will cover hospitals, 
residential treatment facilities, non-residential treatment 
settings, medical treatment or social service settings in 
correctional or detention facilities, psychiatric treatment 
facilities, substance use disorder treatment centers, community 
care settings such as group homes and mental health clinics, 
freestanding emergency centers, federal health care facilities 
such as those operated by the Veterans Administration and the 
Indian Health Service, field work settings such as home care 
and home-based hospice, and emergency services and transport 
services. The standards would not cover employer-provided 
health care facilities.
    The interim and final standards cover direct-hire 
employees, contracted and subcontracted employees, and 
temporary or leased employees employed by a covered employer at 
a covered facility or performing covered services on behalf of 
a covered employer. However, the interim and final standards 
exclude an individual who privately employs persons in the 
individual's residence to perform covered services for the 
individual or a family member of the individual.

Section 103. Requirements for the Workplace Violence Prevention 
        Standard

    The legislation directs OSHA to establish a standard that:
    (1) Requires each covered employer to develop and implement 
a Workplace Violence Prevention Plan (Plan) tailored to the 
relevant hazards in the specific facility.
           In preparing a Plan, covered employers, in 
        conjunction with employees (and their representatives 
        where applicable), shall identify workplace violence 
        risks to employees in their particular workplace, 
        including environmental risk factors, risk factors 
        specific to the patient population, and past violent 
        incidents.
           Covered employers are responsible for 
        implementing techniques or interventions that prevent 
        hazards.
    (2) Requires that the Plan include, as appropriate to the 
particular work setting, both work practice controls such as 
security, staffing, and training on de-escalation techniques, 
and engineering controls such as personal alarm devices, 
adequate exit routes, surveillance monitoring systems, barrier 
protection, entry procedures, and weapons detectors. The Plan 
must outline procedures for reporting, responding to, and 
investigating incidents, and providing medical care and first 
aid to affected employees. The Plan must include procedures for 
training of the workforce, coordination with other employers 
who have employees who work at the site, and an annual 
evaluation of the Plan.
    (3) Requires that covered employers investigate each 
incident of workplace violence as soon as practicable, document 
the findings, and take corrective measures.
    (4) Requires that each covered employer provide annual in-
person training and education to employees, although annual 
refresher training may be done through live video conference if 
in-person training is impracticable. When employees are 
reassigned, they must receive additional training.
    (5) Requires that employers must record workplace violence 
incidents in a Violent Incident Log (Log). An annual summary of 
the Log shall be posted in the workplace in the same manner as 
the posting of the OSHA Annual Summary of Injuries and 
Illnesses, and similarly, the summary of the Log shall be 
transmitted to OSHA on an annual basis. Employers shall 
maintain records related to the Plan, and employees are 
provided the right to examine and make copies of the Plan, the 
Log, and related Plan documents, with appropriate protections 
for patient and worker privacy. Patient names and personal 
identifying information will be excluded from the Log.
    (6) Requires each covered employer to report to OSHA on an 
annual basis the frequency, quantity, and severity of workplace 
violence, and any incident response and post incident 
investigation (including abatement measures) for the incidents 
set forth in the summary of the Log.
    (7) Requires each covered employer to conduct an annual 
evaluation, with the participation of covered employees and 
their representatives, on the implementation and the 
effectiveness of the Plan, including a review of the Log and 
the required training.
    (8) Prohibits retaliation by a covered employer against a 
covered employee for reporting a workplace violence incident, 
threat, or concern to an employer, law enforcement, local 
emergency services, or a government agency. A violation of this 
prohibition shall be enforceable as a violation of an OSHA 
standard. Covered employers must adopt a policy prohibiting 
retaliation.

Section 104. Rules of construction

    This section states that nothing in this legislation 
curtails or limits the authority of the Secretary of Labor 
under any other provision of federal or state law or any 
collective bargaining agreement. The rights, privileges, and 
remedies of employees provided under this legislation are in 
addition to those provided under any other federal or state 
law.

Section 105. Key definitions

    This section includes key definitions. The term ``workplace 
violence'' means: (i) any act of violence or threat of 
violence, without regard to intent, and includes the threat or 
use of physical force against an employee that results in or 
has a high likelihood of resulting in physical injury, 
psychological trauma, or stress, without regard to whether an 
employee sustains actual physical injury, psychological trauma, 
or stress; and (ii) an incident involving the threat or use of 
a firearm or a dangerous weapon, including the use of common 
objects as weapons, without regard to whether an employee 
sustains an actual injury, psychological trauma, or stress.
    The terms ``Type 1 violence'' (criminal intent), ``Type 2 
violence'' (customer or client initiated), ``Type 3 violence'' 
(worker on worker) and ``Type 4 violence'' (personal 
relationships) are incorporated based on the nomenclature 
developed by the National Institute for Occupational Safety and 
Health.
    The term ``engineering controls'' means: an aspect of the 
built space or a device that removes a hazard from the 
workplace or creates a barrier between a covered employee and 
the hazard. This includes electronic access controls to 
employee occupied areas, weapons detectors (installed or 
handheld), enclosed workstations with shatter-resistant glass, 
deep service counters, separate rooms or areas for high risk 
patients, locks on doors, removing access to or securing items 
that could be used as weapons, furniture affixed to floors, 
opaque glass in patient rooms (which protects privacy, but 
allows the health care provider to see where the patent is 
before entering the room), closed circuit monitoring and video 
recording, sight aids, and personal alarm devices.
    The term ``work practice controls'' means: procedures and 
rules that are used to effectively reduce workplace violence, 
which include (i) assigning and placing sufficient numbers of 
staff to reduce patient-specific Type 2 workplace violence 
hazards; (ii) provision of dedicated and available safety 
personnel, such as security guards; (iii) employee training on 
workplace violence prevention methods and techniques to de-
escalate and minimize violent behavior; and (iv) employee 
training on procedures for response in the event of a workplace 
violence incident and for post-incident response.

            Title II. Amendments to the Social Security Act


Section 201. Application of the workplace violence prevention standard 
        to certain facilities receiving Medicare funds

    This section requires that hospitals and skilled nursing 
facilities operated by state or local government agencies, 
which are not otherwise subject to the OSH Act or a state 
occupational safety and health plan, shall comply with the OSHA 
standard required in this Act as a condition of receiving 
Medicare funds. A covered facility that fails to comply with 
the OSHA standard is subject to a civil monetary penalty in an 
amount similar to the amount OSHA may impose under the OSH Act 
for a violation of a standard, but such facility is not subject 
to termination of an agreement with Medicare for failure to 
comply.

                       Explanation of Amendments

    The amendments, including the amendment in the nature of a 
substitute, are explained in the descriptive portions of this 
report.

              Application of Law to the Legislative Branch

    H.R. 1309 does not apply to terms and conditions of 
employment or to access to public services or accommodations 
within the legislative branch.

                       Unfunded Mandate Statement

    The Committee adopts as its own the estimate of federal 
mandates regarding H.R. 1309, as amended, prepared by the 
Director of the Congressional Budget Office (CBO), with the 
following qualifications.
    The CBO's Unfunded Mandates Reform Act estimate 
significantly overstates the cost of this legislation because 
it assumes that H.R. 1309 covers hundreds of thousands of 
facilities that were not included within the list of ``covered 
facilities'' delineated in the scope of H.R. 1309. For example, 
the CBO estimate erroneously assumed that most ambulatory 
health care services including physicians' offices, dentists, 
chiropractors, and podiatrists were covered under Section 102 
of this bill. In developing its estimate, CBO relied on OSHA's 
interpretation of which ``covered facilities'' were included 
within this legislation; however, pursuant to CBO policy, CBO 
was not allowed to provide the Committee with the cost 
information that CBO used to develop its cost estimate. 
Furthermore, OSHA has declined to authorize CBO to share this 
information with the Committee as of the date of this report. 
In order to clarify the intent and cost of this legislation, 
the Committee intends to submit a Manager's Amendment when this 
bill is considered by the full House of Representatives that 
will expressly exclude a large number of covered facilities 
that were inappropriately included in the cost estimate and 
that is expected to result in a reduced UMRA estimate.

                           Earmark Statement

    In accordance with clause 9 of rule XXI of the Rules of the 
House of Representatives, H.R. 1309 does not contain any 
congressional earmarks, limited tax benefits, or limited tariff 
benefits as described in clauses 9(e), 9(f), and 9(g) of rule 
XXI.

                            Roll Call Votes

    In compliance with clause 3(b) of rule XIII of the Rules of 
the House of Representatives, the Committee advises that the 
following roll call votes occurred during the Committee's 
consideration of H.R. 1309:


             Statement of Performance Goals and Objectives

    Pursuant to clause (3)(c) of rule XIII of the Rules of the 
House of Representatives, the goals of H.R. 1309 are to protect 
health care and social service workers from workplace violence.

                    Duplication of Federal Programs

    Pursuant to clause 3(c)(5) of rule XIII of the Rules of the 
House of Representatives, the Committee states that no 
provision of H.R. 1309 establishes or reauthorizes a program of 
the Federal Government known to be duplicative of another 
federal program, a program that was included in any report from 
the Government Accountability Office to Congress pursuant to 
section 21 of Public Law 111-139, or a program related to a 
program identified in the most recent Catalog of Federal 
Domestic Assistance.

                                Hearings

    Pursuant to section 103(i) of H. Res. 6 for the 116th 
Congress, on February 27, 2019, the Committee held a 
legislative hearing entitled ``Caring for Our Caregivers: 
Protecting Health Care and Social Service Workers from 
Workplace Violence,'' which was used to consider H.R. 1309. The 
Committee heard testimony on: existing standards for prevention 
and reporting measures for workplace violence; the challenges 
that victims' experience; and methods that would provide 
effective protections to current workers to prevent workplace 
violence. The Committee heard testimony from: Jane Lipscomb, 
retired Ph.D. RN from the University of Maryland School of 
Nursing; Angelo McClain, Ph.D. LICSW Chief Executive Officer of 
the National Association of Social Workers; Patricia Moon-
Updike, a former Psychiatric RN; and Manesh K. Rath, Partner at 
Keller and Heckman.

      Statement of Oversight and Recommendations of the Committee

    In compliance with clause 3(c)(1) of rule XIII and clause 
2(b)(1) of rule X of the Rules of the House of Representatives, 
the Committee's oversight findings and recommendations are 
reflected in the descriptive portions of this report.

               New Budget Authority and CBO Cost Estimate

    Pursuant to clause 3(c)(2) of rule XIII of the Rules of the 
House of Representatives and section 308(a) of the 
Congressional Budget Act of 1974, and pursuant to clause 
3(c)(3) of rule XIII of the Rules of the House of 
Representatives and section 402 of the Congressional Budget Act 
of 1974, the Committee has received the following estimate for 
H.R. 1309 from the Director of the Congressional Budget Office:

                                     U.S. Congress,
                               Congressional Budget Office,
                                   Washington, DC, October 9, 2019.
Hon. Bobby Scott,
Chairman, Committee on Education and Labor,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 1309, the 
Workplace Violence Prevention for Health Care and Social 
Service Workers Act.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Sofia Guo.
            Sincerely,
                                             Mark P. Hadley
                                 (For Phillip L. Swagel, Director).
    Enclosure.

    
    

    The bill would:
           Require the Secretary of Labor to issue an 
        interim final standard, a proposed standard, and a 
        final rule to prevent workplace violence based on 
        existing Occupational Safety and Health Administration 
        (OSHA) guidelines
           Require certain employers in the health care 
        and social service sectors and employers conducting 
        related activities in those sectors to develop and 
        implement plans to protect against and prevent 
        workplace violence
           Require hospitals and skilled nursing 
        facilities to comply with the new standard as a 
        condition of a Medicare provider agreement
           Impose intergovernmental and private-sector 
        mandates by requiring facilities to comply with the 
        OSHA standard
    Estimated budgetary effects would primarily stem from:
           Changes in Medicare payments to certain 
        affected facilities to defray increased administrative 
        and capital costs
           Spending by OSHA to develop the standards, 
        assuming appropriation of authorized amounts
    Areas of significant uncertainty include:
           Predicting the requirements of the final 
        standard
           Estimating the extent to which covered 
        entities are already complying with the OSHA guidelines
           Estimating the reduction in workplace 
        violence associated with the new requirements
    Bill summary: H.R. 1309 would require the Secretary of 
Labor to issue an interim final standard, a proposed standard, 
and a final rule that would require certain employers in the 
health care and social service sectors as well as employers 
conducting related activities in those sectors to develop and 
implement plans to prevent and protect against workplace 
violence. The plans, at a minimum, would have to be based on 
the Guidelines for Preventing Workplace Violence for Healthcare 
and Social Service Workers published by the Occupational Safety 
and Health Administration in 2016 and meet other requirements 
in the bill.
    Estimated Federal cost: The estimated budgetary effect of 
H.R. 1309 is shown in Table 1. The costs of the legislation 
fall within budget functions 550 (health) and 570 (Medicare).

                                                   TABLE 1.--ESTIMATED BUDGETARY EFFECTS OF H.R. 1309
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                         By fiscal year, millions of dollars--
                                                             -------------------------------------------------------------------------------------------
                                                               2020   2021   2022   2023   2024   2025   2026   2027   2028   2029  2020-2024  2020-2029
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                              Increases in Direct Spending
 
Estimated Budget Authority..................................      0      5     10     15      5      5      5      5      5      5         35         60
Estimated Outlays...........................................      0      5     10     15      5      5      5      5      5      5         35         60
                                                     Increases in Spending Subject to Appropriation
 
Estimated Authorization.....................................      6      4      4      2      *   n.e.   n.e.   n.e.   n.e.   n.e.         16       n.e.
                      Estimated Outlays                           6      4      4      2      *   n.e.   n.e.   n.e.   n.e.   n.e.         16       n.e.
--------------------------------------------------------------------------------------------------------------------------------------------------------
n.e. = not estimated; * = between zero and $500,000.

    Basis of estimate: For this estimate, CBO assumes that the 
legislation will be enacted near the end of 2019 and that the 
authorized and necessary amounts will be provided in each year. 
Outlays were estimated using information from OSHA and the 
Bureau of Labor Statistics (BLS).
    Direct spending: Because H.R. 1309 would require health 
care facilities to implement plans to safeguard against 
workplace violence, the cost of operating health care 
facilities would increase. The costs would stem from activities 
such as annual training of personnel, development and 
implementation of plans to prevent violence in the workplace, 
and development and maintenance of certain changes to 
infrastructure. CBO estimated the cost of compliance for 
hospitals that do not already meet the new standards using data 
from OSHA. Those costs would be partially offset by savings 
from a decrease in payments for workers' compensation claims 
resulting from workplace violence. CBO estimated those savings 
using data from BLS on the cost of claims for workers' 
compensation and the share of those claims related to workplace 
violence in hospitals. Some of the affected facilities receive 
Medicare payments based on the cost of their operations; 
therefore, enacting the bill would increase costs to Medicare 
for those payments. On net, CBO estimates, enacting H.R. 1309 
would increase direct spending by $60 million over the 2020-
2029 period, with the cost in early years of coming into 
compliance exceeding the cost in subsequent years of 
maintaining compliance with the standards.
    Spending subject to appropriation: Implementing H.R. 1309 
would increase costs for the Department of Labor. Using 
information from OSHA, CBO estimates that DOL would need 20 
additional employees, at an average annual cost of $160,000 
each, as well as additional contractors to support the 
rulemaking process and to improve the information technology 
systems that would handle new record-keeping requirements. Such 
spending would be subject to the availability of appropriated 
funds. CBO expects that it would take about four years to 
complete the requirements. On that basis, CBO estimates that 
implementing the bill would cost $16 million over the 2020-2024 
period.
    Uncertainty: The estimated costs are subject to a fair 
amount of uncertainty. For example, CBO cannot predict 
precisely what the requirements in the final standard would 
entail. CBO is also uncertain about which covered entities are 
already in compliance with the proposed requirements, and the 
extent to which those requirements would reduce workplace 
violence. The bill describes only the minimum requirements for 
the final standard. If the final standard is substantially 
different from that minimum, direct spending could be higher or 
lower. Also, the number of covered entities already in 
compliance with the proposed requirements could be different 
than CBO estimates. Finally, this estimate takes into account 
savings to covered entities from a decrease in workplace 
violence. If that decrease is larger or smaller than CBO 
estimates, spending would be lower or higher.
    Pay-as-you-go considerations: The Statutory Pay-As-You-Go 
Act of 2010 establishes budget-reporting and enforcement 
procedures for legislation affecting direct spending or 
revenues. The net changes in outlays that are subject to those 
pay-as-you-go procedures are shown in Table 2.

                                      TABLE 2.--CBO'S ESTIMATE OF THE STATUTORY PAY-AS-YOU-GO EFFECTS OF H.R. 1309
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                    By fiscal year, millions of dollars--
                                                   -----------------------------------------------------------------------------------------------------
                                                     2020    2021    2022    2023    2024    2025    2026    2027    2028    2029   2020-2024  2020-2029
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                               Net Increase in the Deficit
 
Pay-As-You-Go Effect..............................       0       5      10      15       5       5       5       5       5       5         35         60
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Increase in long-term deficits: CBO estimates that enacting 
H.R. 1309 would not increase on-budget deficits by more than $5 
billion in any of the four consecutive 10-year periods 
beginning in 2030.
    Mandates: H.R. 1309 would impose intergovernmental and 
private-sector mandates as defined in the Unfunded Mandates 
Reform Act (UMRA) on health care and social service facilities 
by requiring them to comply with the new OSHA rule.
    Because the bill would apply to health care facilities 
broadly, it would affect public facilities, including hospitals 
and skilled nursing centers operated by state and local 
governments. CBO estimates that in the first two years in which 
the final rule is in effect, the annual public-sector cost of 
the mandates would be at least $100 million and would exceed 
the intergovernmental threshold established in UMRA ($82 
million in 2019, adjusted annually for inflation) in those 
years. In later years, CBO estimates, public entities would 
spend at least $55 million annually to comply.
    CBO estimates that the cost to private entities would be at 
least $2.7 billion in the first two years the final rule is in 
effect and at least $1.3 billion annually thereafter. Those 
costs would exceed the private-sector threshold ($164 million 
in 2019, adjusted annually for inflation) in each of the first 
five years in which the rule was in effect.
    H.R. 1309 would impose mandates on covered facilities by 
requiring them to:
           Provide annual staff training;
           Investigate violent incidents;
           Develop violence prevention plans that 
        include risk assessment, hazard correction, and 
        infrastructure upgrades;
           Maintain and retain related records for at 
        least five years; and
           Report and evaluate information as required 
        by the OSHA rule.
    In particular, substantial personnel and capital costs 
would be imposed by the requirements for training, 
investigation, engineering, and infrastructure changes. Those 
costs would be mitigated because some states already require 
similar duties. In addition, the Occupational Safety and Health 
Act has limited applicability to state and local government 
employees, and some facilities now comply voluntarily with the 
standards in the bill.
    Using information provided by OSHA, CBO expects that the 
rule would affect hundreds of thousands of mostly private 
facilities, including ambulatory care centers, hospitals, 
freestanding emergency centers, and nursing homes and other 
residential facilities. Most of the covered entities are small 
facilities that would incur costs related to developing plans 
and training employees. Costs to those facilities would 
constitute about one-third of the mandate cost overall but 
would be relatively small for each facility.
    CBO estimates that larger facilities, particularly 
hospitals and nursing homes, would incur significant and 
uncertain costs because of the possibility of more frequent 
incidents and the likelihood of expensive infrastructure 
changes. Based on published research, CBO expects that 
compliance with the mandate would lead to savings in workers' 
compensation expenses and would reduce the cost of the mandate. 
Although CBO assumes that entities would comply in the most 
cost-effective manner, the cost of the mandate could rise 
significantly if the number and nature of violent incidents 
required additional staff training and infrastructure changes.
    Estimate prepared by: Federal Costs: Sofia Guo (OSHA), 
Jamease Kowalczyk and Sarah Sajewski (Medicare); Mandates: 
Andrew Laughlin.
    Estimate reviewed by: Kim Cawley, Chief, Natural and 
Physical Resources Cost Estimates Unit; Tom B. Bradley, Chief, 
Health Systems and Medicare Cost Estimates Unit; Susan Willie, 
Chief, Mandates Unit; H. Samuel Papenfuss, Deputy Assistant 
Director for Budget Analysis; Theresa Gullo, Assistant Director 
for Budget Analysis.

                        Committee Cost Estimate

    Clause 3(d)(1) of rule XIII of the Rules of the House of 
Representatives requires an estimate and a comparison of the 
costs that would be incurred in carrying out H.R. 1309. 
However, clause 3(d)(2)(B) of that rule provides that this 
requirement does not apply when the committee has included in 
its report a timely submitted cost estimate of the bill 
prepared by the Director of the Congressional Budget Office 
under section 402 of the Congressional Budget Act of 1974.

         Changes in Existing Law Made by the Bill, as Reported

    In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, H.R. 1309, as reported, are shown as follows:

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, and existing law in which no 
change is proposed is shown in roman):

                          SOCIAL SECURITY ACT




           *       *       *       *       *       *       *
TITLE XVIII--HEALTH INSURANCE FOR THE AGED AND DISABLED

           *       *       *       *       *       *       *



Part E--Miscellaneous Provisions

           *       *       *       *       *       *       *



      agreements with providers of services; enrollment processes

  Sec. 1866. (a)(1) Any provider of services (except a fund 
designated for purposes of section 1814(g) and section 1835(e)) 
shall be qualified to participate under this title and shall be 
eligible for payments under this title if it files with the 
Secretary an agreement--
          (A)(i) not to charge, except as provided in paragraph 
        (2), any individual or any other person for items or 
        services for which such individual is entitled to have 
        payment made under this title (or for which he would be 
        so entitled if such provider of services had complied 
        with the procedural and other requirements under or 
        pursuant to this title or for which such provider is 
        paid pursuant to the provisions of section 1814(e)), 
        and (ii) not to impose any charge that is prohibited 
        under section 1902(n)(3),
          (B) not to charge any individual or any other person 
        for items or services for which such individual is not 
        entitled to have payment made under this title because 
        payment for expenses incurred for such items or 
        services may not be made by reason of the provisions of 
        paragraph (1) or (9) of section 1862(a), but only if 
        (i) such individual was without fault in incurring such 
        expenses and (ii) the Secretary's determination that 
        such payment may not be made for such items and 
        services was made after the third year following the 
        year in which notice of such payment was sent to such 
        individual; except that the Secretary may reduce such 
        three-year period to not less than one year if he finds 
        such reduction is consistent with the objectives of 
        this title,
          (C) to make adequate provision for return (or other 
        disposition, in accordance with regulations) of any 
        moneys incorrectly collected from such individual or 
        other person,
          (D) to promptly notify the Secretary of its 
        employment of an individual who, at any time during the 
        year preceding such employment, was employed in a 
        managerial, accounting, auditing, or similar capacity 
        (as determined by the Secretary by regulation) by an 
        agency or organization which serves as a fiscal 
        intermediary or carrier (for purposes of part A or part 
        B, or both, of this title) with respect to the 
        provider,
          (E) to release data with respect to patients of such 
        provider upon request to an organization having a 
        contract with the Secretary under part B of title XI as 
        may be necessary (i) to allow such organization to 
        carry out its functions under such contract, or (ii) to 
        allow such organization to carry out similar review 
        functions under any contract the organization may have 
        with a private or public agency paying for health care 
        in the same area with respect to patients who authorize 
        release of such data for such purposes,
          (F)(i) in the case of hospitals which provide 
        inpatient hospital services for which payment may be 
        made under subsection (b), (c), or (d) of section 1886, 
        to maintain an agreement with a professional standards 
        review organization (if there is such an organization 
        in existence in the area in which the hospital is 
        located) or with a quality improvement organization 
        which has a contract with the Secretary under part B of 
        title XI for the area in which the hospital is located, 
        under which the organization will perform functions 
        under that part with respect to the review of the 
        validity of diagnostic information provided by such 
        hospital, the completeness, adequacy, and quality of 
        care provided, the appropriateness of admissions and 
        discharges, and the appropriateness of care provided 
        for which additional payments are sought under section 
        1886(d)(5), with respect to inpatient hospital services 
        for which payment may be made under part A of this 
        title (and for purposes of payment under this title, 
        the cost of such agreement to the hospital shall be 
        considered a cost incurred by such hospital in 
        providing inpatient services under part A, and (I) 
        shall be paid directly by the Secretary to such 
        organization on behalf of such hospital in accordance 
        with a rate per review established by the Secretary, 
        (II) shall be transferred from the Federal Hospital 
        Insurance Trust Fund, without regard to amounts 
        appropriated in advance in appropriation Acts, in the 
        same manner as transfers are made for payment for 
        services provided directly to beneficiaries, and (III) 
        shall not be less in the aggregate for a fiscal year 
        than the aggregate amount expended in fiscal year 1988 
        for direct and administrative costs (adjusted for 
        inflation and for any direct or administrative costs 
        incurred as a result of review functions added with 
        respect to a subsequent fiscal year) of such reviews),
          (ii) in the case of hospitals, critical access 
        hospitals, skilled nursing facilities, and home health 
        agencies, to maintain an agreement with a quality 
        improvement organization (which has a contract with the 
        Secretary under part B of title XI for the area in 
        which the hospital, facility, or agency is located) to 
        perform the functions described in paragraph (3)(A),
          (G) in the case of hospitals which provide inpatient 
        hospital services for which payment may be made under 
        subsection (b) or (d) of section 1886, not to charge 
        any individual or any other person for inpatient 
        hospital services for which such individual would be 
        entitled to have payment made under part A but for a 
        denial or reduction of payments under section 
        1886(f)(2),
          (H)(i) in the case of hospitals which provide 
        services for which payment may be made under this title 
        and in the case of critical access hospitals which 
        provide critical access hospital services, to have all 
        items and services (other than physicians' services as 
        defined in regulations for purposes of section 
        1862(a)(14), and other than services described by 
        section 1861(s)(2)(K), certified nurse-midwife 
        services, qualified psychologist services, and services 
        of a certified registered nurse anesthetist) (I) that 
        are furnished to an individual who is a patient of the 
        hospital, and (II) for which the individual is entitled 
        to have payment made under this title, furnished by the 
        hospital or otherwise under arrangements (as defined in 
        section 1861(w)(1)) made by the hospital,
          (ii) in the case of skilled nursing facilities which 
        provide covered skilled nursing facility services--
                  (I) that are furnished to an individual who 
                is a resident of the skilled nursing facility 
                during a period in which the resident is 
                provided covered post-hospital extended care 
                services (or, for services described in section 
                1861(s)(2)(D), that are furnished to such an 
                individual without regard to such period), and
                  (II) for which the individual is entitled to 
                have payment made under this title,
        to have items and services (other than services 
        described in section 1888(e)(2)(A)(ii)) furnished by 
        the skilled nursing facility or otherwise under 
        arrangements (as defined in section 1861(w)(1)) made by 
        the skilled nursing facility,
          (I) in the case of a hospital or critical access 
        hospital--
                  (i) to adopt and enforce a policy to ensure 
                compliance with the requirements of section 
                1867 and to meet the requirements of such 
                section,
                  (ii) to maintain medical and other records 
                related to individuals transferred to or from 
                the hospital for a period of five years from 
                the date of the transfer, and
                  (iii) to maintain a list of physicians who 
                are on call for duty after the initial 
                examination to provide treatment necessary to 
                stabilize an individual with an emergency 
                medical condition,
          (J) in the case of hospitals which provide inpatient 
        hospital services for which payment may be made under 
        this title, to be a participating provider of medical 
        care under any health plan contracted for under section 
        1079 or 1086 of title 10, or under section 613 of title 
        38, United States Code, in accordance with admission 
        practices, payment methodology, and amounts as 
        prescribed under joint regulations issued by the 
        Secretary and by the Secretaries of Defense and 
        Transportation, in implementation of sections 1079 and 
        1086 of title 10, United States Code,
          (K) not to charge any individual or any other person 
        for items or services for which payment under this 
        title is denied under section 1154(a)(2) by reason of a 
        determination under section 1154(a)(1)(B),
          (L) in the case of hospitals which provide inpatient 
        hospital services for which payment may be made under 
        this title, to be a participating provider of medical 
        care under section 603 of title 38, United States Code, 
        in accordance with such admission practices, and such 
        payment methodology and amounts, as are prescribed 
        under joint regulations issued by the Secretary and by 
        the Secretary of Veterans Affairs in implementation of 
        such section,
  Section 144(a)(2) of Public Law 115-182 provides for an 
amendment to strike ``under section 603'' and insert ``under 
chapter 17''. Subsection (b) of such section 144 provides 
``[t]he amendments made by subsection (a) shall take effect on 
the date described in section 101(b).''. Paragraphs (1) and (2) 
of section 101(b) of such Public Law provides: ``(1) the date 
that is 30 days after the date on which the Secretary of 
Veterans Affairs submits the report required under section 
101(q)(2) of the Veterans Access, Choice, and Accountability 
Act of 2014 (Public Law 113-146; 38 U.S.C. 1701 note); or (2) 
the date on which the Secretary promulgates regulations 
pursuant to subsection (c).''.
          (M) in the case of hospitals, to provide to each 
        individual who is entitled to benefits under part A (or 
        to a person acting on the individual's behalf), at or 
        about the time of the individual's admission as an 
        inpatient to the hospital, a written statement 
        (containing such language as the Secretary prescribes 
        consistent with this paragraph) which explains--
                  (i) the individual's rights to benefits for 
                inpatient hospital services and for post-
                hospital services under this title,
                  (ii) the circumstances under which such an 
                individual will and will not be liable for 
                charges for continued stay in the hospital,
                  (iii) the individual's right to appeal 
                denials of benefits for continued inpatient 
                hospital services, including the practical 
                steps to initiate such an appeal, and
                  (iv) the individual's liability for payment 
                for services if such a denial of benefits is 
                upheld on appeal,--and which provides such 
                additional information as the Secretary may 
                specify,
          (N) in the case of hospitals and critical access 
        hospitals--
                  (i) to make available to its patients the 
                directory or directories of participating 
                physicians (published under section 1842(h)(4)) 
                for the area served by the hospital or critical 
                access hospital,
                  (ii) if hospital personnel (including staff 
                of any emergency or outpatient department) 
                refer a patient to a nonparticipating physician 
                for further medical care on an outpatient 
                basis, the personnel must inform the patient 
                that the physician is a nonparticipating 
                physician and, whenever practicable, must 
                identify at least one qualified participating 
                physician who is listed in such a directory and 
                from whom the patient may receive the necessary 
                services,
                  (iii) to post conspicuously in any emergency 
                department a sign (in a form specified by the 
                Secretary) specifying rights of individuals 
                under section 1867 with respect to examination 
                and treatment for emergency medical conditions 
                and women in labor, and
                  (iv) to post conspicuously (in a form 
                specified by the Secretary) information 
                indicating whether or not the hospital 
                participates in the medicaid program under a 
                State plan approved under title XIX,
          (O) to accept as payment in full for services that 
        are covered under this title and are furnished to any 
        individual enrolled with a Medicare+Choice organization 
        under part C, with a PACE provider under section 1894 
        or 1934, or with an eligible organization with a risk-
        sharing contract under section 1876, under section 
        1876(i)(2)(A) (as in effect before February 1, 1985), 
        under section 402(a) of the Social Security Amendments 
        of 1967, or under section 222(a) of the Social Security 
        Amendments of 1972, which does not have a contract (or, 
        in the case of a PACE provider, contract or other 
        agreement) establishing payment amounts for services 
        furnished to members of the organization or PACE 
        program eligible individuals enrolled with the PACE 
        provider, the amounts that would be made as a payment 
        in full under this title (less any payments under 
        sections 1886(d)(11) and 1886(h)(3)(D)) if the 
        individuals were not so enrolled,
          (P) in the case of home health agencies which provide 
        home health services to individuals entitled to 
        benefits under this title who require catheters, 
        catheter supplies, ostomy bags, and supplies related to 
        ostomy car (described in section 1861(m)(5)), to offer 
        to furnish such supplies to such an individual as part 
        of their furnishing of home health services,
          (Q) in the case of hospitals, skilled nursing 
        facilities, home health agencies, and hospice programs, 
        to comply with the requirement of subsection (f) 
        (relating to maintaining written policies and 
        procedures respecting advance directives),
          (R) to contract only with a health care clearinghouse 
        (as defined in section 1171) that meets each standard 
        and implementation specification adopted or established 
        under part C of title XI on or after the date on which 
        the health care clearinghouse is required to comply 
        with the standard or specification,
          (S) in the case of a hospital that has a financial 
        interest (as specified by the Secretary in regulations) 
        in an entity to which individuals are referred as 
        described in section 1861(ee)(2)(H)(ii), or in which 
        such an entity has such a financial interest, or in 
        which another entity has such a financial interest 
        (directly or indirectly) with such hospital and such an 
        entity, to maintain and disclose to the Secretary (in a 
        form and manner specified by the Secretary) information 
        on--
                  (i) the nature of such financial interest,
                  (ii) the number of individuals who were 
                discharged from the hospital and who were 
                identified as requiring home health services, 
                and
                  (iii) the percentage of such individuals who 
                received such services from such provider (or 
                another such provider),
          (T) in the case of hospitals and critical access 
        hospitals, to furnish to the Secretary such data as the 
        Secretary determines appropriate pursuant to 
        subparagraph (E) of section 1886(d)(12) to carry out 
        such section,
          (U) in the case of hospitals which furnish inpatient 
        hospital services for which payment may be made under 
        this title, to be a participating provider of medical 
        care both--
                  (i) under the contract health services 
                program funded by the Indian Health Service and 
                operated by the Indian Health Service, an 
                Indian tribe, or tribal organization (as those 
                terms are defined in section 4 of the Indian 
                Health Care Improvement Act), with respect to 
                items and services that are covered under such 
                program and furnished to an individual eligible 
                for such items and services under such program; 
                and
                  (ii) under any program funded by the Indian 
                Health Service and operated by an urban Indian 
                organization with respect to the purchase of 
                items and services for an eligible urban Indian 
                (as those terms are defined in such section 4),
        in accordance with regulations promulgated by the 
        Secretary regarding admission practices, payment 
        methodology, and rates of payment (including the 
        acceptance of no more than such payment rate as payment 
        in full for such items and services,
          (V) in the case of hospitals that are not otherwise 
        subject to the Occupational Safety and Health Act of 
        1970 (or a State occupational safety and health plan 
        that is approved under 18(b) of such Act), to comply 
        with the Bloodborne Pathogens standard under section 
        1910.1030 of title 29 of the Code of Federal 
        Regulations (or as subsequently redesignated),
          (W) in the case of a hospital described in section 
        1886(d)(1)(B)(v), to report quality data to the 
        Secretary in accordance with subsection (k),
          (X) maintain and, upon request of the Secretary, 
        provide access to documentation relating to written 
        orders or requests for payment for durable medical 
        equipment, certifications for home health services, or 
        referrals for other items or services written or 
        ordered by the provider under this title, as specified 
        by the Secretary, [and]
          (Y) beginning 12 months after the date of the 
        enactment of this subparagraph, in the case of a 
        hospital or critical access hospital, with respect to 
        each individual who receives observation services as an 
        outpatient at such hospital or critical access hospital 
        for more than 24 hours, to provide to such individual 
        not later than 36 hours after the time such individual 
        begins receiving such services (or, if sooner, upon 
        release)--
                  (i) such oral explanation of the written 
                notification described in clause (ii), and such 
                documentation of the provision of such 
                explanation, as the Secretary determines to be 
                appropriate;
                  (ii) a written notification (as specified by 
                the Secretary pursuant to rulemaking and 
                containing such language as the Secretary 
                prescribes consistent with this paragraph) 
                which--
                          (I) explains the status of the 
                        individual as an outpatient receiving 
                        observation services and not as an 
                        inpatient of the hospital or critical 
                        access hospital and the reasons for 
                        such status of such individual;
                          (II) explains the implications of 
                        such status on services furnished by 
                        the hospital or critical access 
                        hospital (including services furnished 
                        on an inpatient basis), such as 
                        implications for cost-sharing 
                        requirements under this title and for 
                        subsequent eligibility for coverage 
                        under this title for services furnished 
                        by a skilled nursing facility;
                          (III) includes such additional 
                        information as the Secretary determines 
                        appropriate;
                          (IV) either--
                                  (aa) is signed by such 
                                individual or a person acting 
                                on such individual's behalf to 
                                acknowledge receipt of such 
                                notification; or
                                  (bb) if such individual or 
                                person refuses to provide the 
                                signature described in item 
                                (aa), is signed by the staff 
                                member of the hospital or 
                                critical access hospital who 
                                presented the written 
                                notification and includes the 
                                name and title of such staff 
                                member, a certification that 
                                the notification was presented, 
                                and the date and time the 
                                notification was presented; and
                          (V) is written and formatted using 
                        plain language and is made available in 
                        appropriate languages as determined by 
                        the Secretary[.]; and
          (Z) in the case of hospitals that are not otherwise 
        subject to the Occupational Safety and Health Act of 
        1970 (or a State occupational safety and health plan 
        that is approved under 18(b) of such Act) and skilled 
        nursing facilities that are not otherwise subject to 
        such Act (or such a State occupational safety and 
        health plan), to comply with the Workplace Violence 
        Prevention Standard (as promulgated under section 101 
        of the Workplace Violence Prevention for Health Care 
        and Social Service Workers Act).
In the case of a hospital which has an agreement in effect with 
an organization described in subparagraph (F), which 
organization's contract with the Secretary under part B of 
title XI is terminated on or after October 1, 1984, the 
hospital shall not be determined to be out of compliance with 
the requirement of such subparagraph during the six month 
period beginning on the date of the termination of that 
contract.
  (2)(A) A provider of services may charge such individual or 
other person (i) the amount of any deduction or coinsurance 
amount imposed pursuant to section 1813(a)(1), (a)(3), or 
(a)(4), section 1833(b), or section 1861(y)(3) with respect to 
such items and services (not in excess of the amount 
customarily charged for such items and services by such 
provider), and (ii) an amount equal to 20 per centum of the 
reasonable charges for such items and services (not in excess 
of 20 per centum of the amount customarily charged for such 
items and services by such provider) for which payment is made 
under part B or which are durable medical equipment furnished 
as home health services (but in the case of items and services 
furnished to individuals with end-stage renal disease, an 
amount equal to 20 percent of the estimated amounts for such 
items and services calculated on the basis established by the 
Secretary). In the case of items and services described in 
section 1833(c), clause (ii) of the preceding sentence shall be 
applied by substituting for 20 percent the proportion which is 
appropriate under such section. A provider of services may not 
impose a charge under clause (ii) of the first sentence of this 
subparagraph with respect to items and services described in 
section 1861(s)(10)(A) and with respect to clinical diagnostic 
laboratory tests for which payment is made under part B. 
Notwithstanding the first sentence of this subparagraph, a home 
health agency may charge such an individual or person, with 
respect to covered items subject to payment under section 
1834(a), the amount of any deduction imposed under section 
1833(b) and 20 percent of the payment basis described in 
section 1834(a)(1)(B). In the case of items and services for 
which payment is made under part B under the prospective 
payment system established under section 1833(t), clause (ii) 
of the first sentence shall be applied by substituting for 20 
percent of the reasonable charge, the applicable copayment 
amount established under section 1833(t)(5). In the case of 
services described in section 1833(a)(8) or section 1833(a)(9) 
for which payment is made under part B under section 1834(k), 
clause (ii) of the first sentence shall be applied by 
substituting for 20 percent of the reasonable charge for such 
services 20 percent of the lesser of the actual charge or the 
applicable fee schedule amount (as defined in such section) for 
such services.
  (B) Where a provider of services has furnished, at the 
request of such individual, items or services which are in 
excess of or more expensive than the items or services with 
respect to which payment may be made under this title, such 
provider of services may also charge such individual or other 
person for such more expensive items or services to the extent 
that the amount customarily charged by it for the items or 
services furnished at such request exceeds the amount 
customarily charged by it for the items or services with 
respect to which payment may be made under this title.
  [(ii) Repealed.]
  (C) A provider of services may in accordance with its 
customary practice also appropriately charge any such 
individual for any whole blood (or equivalent quantities of 
packed red blood cells, as defined under regulations) furnished 
him with respect to which a deductible is imposed under section 
1813(a)(2), except that (i) any excess of such charge over the 
cost to such provider for the blood (or equivalent quantities 
of packed red blood cells, as so defined) shall be deducted 
from any payment to such provider under this title, (ii) no 
such charge may be imposed for the cost of administration of 
such blood (or equivalent quantities of packed red blood cells, 
as so defined), and (iii) such charge may not be made to the 
extent such blood (or equivalent quantities of packed red blood 
cells, as so defined) has been replaced on behalf of such 
individual or arrangements have been made for its replacement 
on his behalf. For purposes of subparagraph (C), whole blood 
(or equivalent quantities of packed red blood cells, as so 
defined) furnished an individual shall be deemed replaced when 
the provider of services is given one pint of blood for each 
pint of blood (or equivalent quantities of packed red blood 
cells, as so defined) furnished such individual with respect to 
which a deduction is imposed under section 1813(a)(2).
  (D) Where a provider of services customarily furnishes items 
or services which are in excess of or more expensive than the 
items or services with respect to which payment may be made 
under this title, such provider, notwithstanding the preceding 
provisions of this paragraph, may not, under the authority of 
section 1866(a)(2)(B)(ii), charge any individual or other 
person any amount for such items or services in excess of the 
amount of the payment which may otherwise be made for such 
items or services under this title if the admitting physician 
has a direct or indirect financial interest in such provider.
  (3)(A) Under the agreement required under paragraph 
(1)(F)(ii), the quality improvement organization must perform 
functions (other than those covered under an agreement under 
paragraph (1)(F)(i)) under the third sentence of section 
1154(a)(4)(A) and under section 1154(a)(14) with respect to 
services, furnished by the hospital, critical access hospital, 
facility, or agency involved, for which payment may be made 
under this title.
  (B) For purposes of payment under this title, the cost of 
such an agreement to the hospital, critical access hospital, 
facility, or agency shall be considered a cost incurred by such 
hospital, critical access hospital, facility, or agency in 
providing covered services under this title and shall be paid 
directly by the Secretary to the quality improvement 
organization on behalf of such hospital, critical access 
hospital, facility, or agency in accordance with a schedule 
established by the Secretary.
  (C) Such payments--
          (i) shall be transferred in appropriate proportions 
        from the Federal Hospital Insurance Trust Fund and from 
        the Federal Supplementary Medical Insurance Trust Fund, 
        without regard to amounts appropriated in advance in 
        appropriation Acts, in the same manner as transfers are 
        made for payment for services provided directly to 
        beneficiaries, and
          (ii) shall not be less in the aggregate for a fiscal 
        year--
                  (I) in the case of hospitals, than the amount 
                specified in paragraph (1)(F)(i)(III), and
                  (II) in the case of facilities, critical 
                access hospitals, and agencies, than the 
                amounts the Secretary determines to be 
                sufficient to cover the costs of such 
                organizations' conducting the activities 
                described in subparagraph (A) with respect to 
                such facilities, critical access hospitals, or 
                agencies under part B of title XI.
  (b)(1) A provider of services may terminate an agreement with 
the Secretary under this section at such time and upon such 
notice to the Secretary and the public as may be provided in 
regulations, except that notice of more than six months shall 
not be required.
  (2) The Secretary may refuse to enter into an agreement under 
this section or, upon such reasonable notice to the provider 
and the public as may be specified in regulations, may refuse 
to renew or may terminate such an agreement after the 
Secretary--
          (A) has determined that the provider fails to comply 
        substantially with the provisions of the agreement, 
        with the provisions of this title and regulations 
        thereunder, or with a corrective action required under 
        section 1886(f)(2)(B),
          (B) has determined that the provider fails 
        substantially to meet the applicable provisions of 
        section 1861,
          (C) has excluded the provider from participation in a 
        program under this title pursuant to section 1128 or 
        section 1128A, or
          (D) has ascertained that the provider has been 
        convicted of a felony under Federal or State law for an 
        offense which the Secretary determines is detrimental 
        to the best interests of the program or program 
        beneficiaries.
  (3) A termination of an agreement or a refusal to renew an 
agreement under this subsection shall become effective on the 
same date and in the same manner as an exclusion from 
participation under the programs under this title becomes 
effective under section 1128(c).
  (4)(A) A hospital that fails to comply with the requirement 
of subsection (a)(1)(V) (relating to the Bloodborne Pathogens 
standard) and a hospital or skilled nursing facility that fails 
to comply with the requirement of subsection (a)(1)(Z) 
(relating to the Workplace Violence Prevention Standard) is 
subject to a civil money penalty in an amount described in 
subparagraph (B), but is not subject to termination of an 
agreement under this section.
  (B) The amount referred to in subparagraph (A) is an amount 
that is similar to the amount of civil penalties that may be 
imposed under section 17 of the Occupational Safety and Health 
Act of 1970 for a violation of the Bloodborne Pathogens 
standard referred to in subsection [(a)(1)(U)] (a)(1)(V) by a 
hospital that is subject to the provisions of such Act (or, in 
the case of a failure to comply with the requirement of 
subsection (a)(1)(Z), for a violation of the Workplace Violence 
Prevention standard referred to in such subsection by a 
hospital or skilled nursing facility, as applicable, that is 
subject to the provisions of such Act).
  (C) A civil money penalty under this paragraph shall be 
imposed and collected in the same manner as civil money 
penalties under subsection (a) of section 1128A are imposed and 
collected under that section.
  (c)(1) Where the Secretary has terminated or has refused to 
renew an agreement under this title with a provider of 
services, such provider may not file another agreement under 
this title unless the Secretary finds that the reason for the 
termination or nonrenewal has been removed and that there is 
reasonable assurance that it will not recur.
  (2) Where the Secretary has terminated or has refused to 
renew an agreement under this title with a provider of 
services, the Secretary shall promptly notify each State agency 
which administers or supervises the administration of a State 
plan approved under title XIX of such termination or 
nonrenewal.
  (d) If the Secretary finds that there is a substantial 
failure to make timely review in accordance with section 
1861(k) of long-stay cases in a hospital, he may, in lieu of 
terminating his agreement with such hospital, decide that, with 
respect to any individual admitted to such hospital after a 
subsequent date specified by him, no payment shall be made 
under this title for inpatient hospital services (including 
inpatient psychiatric hospital services) after the 20th day of 
a continuous period of such services. Such decision may be made 
effective only after such notice to the hospital and to the 
public, as may be prescribed by regulations, and its 
effectiveness shall terminate when the Secretary finds that the 
reason therefor has been removed and that there is reasonable 
assurance that it will not recur. The Secretary shall not make 
any such decision except after reasonable notice and 
opportunity for hearing to the institution or agency affected 
thereby.
  (e) For purposes of this section, the term ``provider of 
services'' shall include--
          (1) a clinic, rehabilitation agency, or public health 
        agency if, in the case of a clinic or rehabilitation 
        agency, such clinic or agency meets the requirements of 
        section 1861(p)(4)(A) (or meets the requirements of 
        such section through the operation of subsection (g) or 
        (ll)(2) of section 1861), or if, in the case of a 
        public health agency, such agency meets the 
        requirements of section 1861(p)(4)(B) (or meets the 
        requirements of such section through the operation of 
        subsection (g) or (ll)(2) of section 1861), but only 
        with respect to the furnishing of outpatient physical 
        therapy services (as therein defined), (through the 
        operation of section 1861(g)) with respect to the 
        furnishing of outpatient occupational therapy services, 
        or (through the operation of section 1861(ll)(2)) with 
        respect to the furnishing of outpatient speech-language 
        pathology;
          (2) a community mental health center (as defined in 
        section 1861(ff)(3)(B)), but only with respect to the 
        furnishing of partial hospitalization services (as 
        described in section 1861(ff)(1)); and
          (3) opioid treatment programs (as defined in 
        paragraph (2) of section 1861(jjj)), but only with 
        respect to the furnishing of opioid use disorder 
        treatment services (as defined in paragraph (1) of such 
        section).
  (f)(1) For purposes of subsection (a)(1)(Q) and sections 
1819(c)(2)(E), 1833(s), 1855(i), 1876(c)(8), and 1891(a)(6), 
the requirement of this subsection is that a provider of 
services, Medicare+Choice organization, or prepaid or eligible 
organization (as the case may be) maintain written policies and 
procedures with respect to all adult individuals receiving 
medical care by or through the provider or organization--
          (A) to provide written information to each such 
        individual concerning--
                  (i) an individual's rights under State law 
                (whether statutory or as recognized by the 
                courts of the State) to make decisions 
                concerning such medical care, including the 
                right to accept or refuse medical or surgical 
                treatment and the right to formulate advance 
                directives (as defined in paragraph (3)), and
                  (ii) the written policies of the provider or 
                organization respecting the implementation of 
                such rights;
          (B) to document in a prominent part of the 
        individual's current medical record whether or not the 
        individual has executed an advance directive;
          (C) not to condition the provision of care or 
        otherwise discriminate against an individual based on 
        whether or not the individual has executed an advance 
        directive;
          (D) to ensure compliance with requirements of State 
        law (whether statutory or as recognized by the courts 
        of the State) respecting advance directives at 
        facilities of the provider or organization; and
          (E) to provide (individually or with others) for 
        education for staff and the community on issues 
        concerning advance directives.
Subparagraph (C) shall not be construed as requiring the 
provision of care which conflicts with an advance directive.
  (2) The written information described in paragraph (1)(A) 
shall be provided to an adult individual--
          (A) in the case of a hospital, at the time of the 
        individual's admission as an inpatient,
          (B) in the case of a skilled nursing facility, at the 
        time of the individual's admission as a resident,
          (C) in the case of a home health agency, in advance 
        of the individual coming under the care of the agency,
          (D) in the case of a hospice program, at the time of 
        initial receipt of hospice care by the individual from 
        the program, and
          (E) in the case of an eligible organization (as 
        defined in section 1876(b)) or an organization provided 
        payments under section 1833(a)(1)(A) or a 
        Medicare+Choice organization, at the time of enrollment 
        of the individual with the organization.
  (3) In this subsection, the term ``advance directive'' means 
a written instruction, such as a living will or durable power 
of attorney for health care, recognized under State law 
(whether statutory or as recognized by the courts of the State) 
and relating to the provision of such care when the individual 
is incapacitated.
  (4) For construction relating to this subsection, see section 
7 of the Assisted Suicide Funding Restriction Act of 1997 
(relating to clarification respecting assisted suicide, 
euthanasia, and mercy killing).
  (g) Except as permitted under subsection (a)(2), any person 
who knowingly and willfully presents, or causes to be 
presented, a bill or request for payment inconsistent with an 
arrangement under subsection (a)(1)(H) or in violation of the 
requirement for such an arrangement, is subject to a civil 
money penalty of not to exceed $2,000. The provisions of 
section 1128A (other than subsections (a) and (b)) shall apply 
to a civil money penalty under the previous sentence in the 
same manner as such provisions apply to a penalty or proceeding 
under section 1128A(a).
  (h)(1)(A) Except as provided in paragraph (2), an institution 
or agency dissatisfied with a determination by the Secretary 
that it is not a provider of services or with a determination 
described in subsection (b)(2) shall be entitled to a hearing 
thereon by the Secretary (after reasonable notice) to the same 
extent as is provided in section 205(b), and to judicial review 
of the Secretary's final decision after such hearing as is 
provided in section 205(g), except that, in so applying such 
sections and in applying section 205(l) thereto, any reference 
therein to the Commissioner of Social Security or the Social 
Security Administration shall be considered a reference to the 
Secretary or the Department of Health and Human Services, 
respectively.
  (B) An institution or agency described in subparagraph (A) 
that has filed for a hearing under subparagraph (A) shall have 
expedited access to judicial review under this subparagraph in 
the same manner as providers of services, suppliers, and 
individuals entitled to benefits under part A or enrolled under 
part B, or both, may obtain expedited access to judicial review 
under the process established under section 1869(b)(2). Nothing 
in this subparagraph shall be construed to affect the 
application of any remedy imposed under section 1819 during the 
pendency of an appeal under this subparagraph.
  (C)(i) The Secretary shall develop and implement a process to 
expedite proceedings under this subsection in which--
          (I) the remedy of termination of participation has 
        been imposed;
          (II) a remedy described in clause (i) or (iii) of 
        section 1819(h)(2)(B) has been imposed, but only if 
        such remedy has been imposed on an immediate basis; or
          (III) a determination has been made as to a finding 
        of substandard quality of care that results in the loss 
        of approval of a skilled nursing facility's nurse aide 
        training program.
  (ii) Under such process under clause (i), priority shall be 
provided in cases of termination described in clause (i)(I).
  (iii) Nothing in this subparagraph shall be construed to 
affect the application of any remedy imposed under section 1819 
during the pendency of an appeal under this subparagraph.
  (2) An institution or agency is not entitled to separate 
notice and opportunity for a hearing under both section 1128 
and this section with respect to a determination or 
determinations based on the same underlying facts and issues.
  (i)(1) If the Secretary determines that a psychiatric 
hospital which has an agreement in effect under this section no 
longer meets the requirements for a psychiatric hospital under 
this title and further finds that the hospital's deficiencies--
          (A) immediately jeopardize the health and safety of 
        its patients, the Secretary shall terminate such 
        agreement; or
          (B) do not immediately jeopardize the health and 
        safety of its patients, the Secretary may terminate 
        such agreement, or provide that no payment will be made 
        under this title with respect to any individual 
        admitted to such hospital after the effective date of 
        the finding, or both.
  (2) If a psychiatric hospital, found to have deficiencies 
described in paragraph (1)(B), has not complied with the 
requirements of this title--
          (A) within 3 months after the date the hospital is 
        found to be out of compliance with such requirements, 
        the Secretary shall provide that no payment will be 
        made under this title with respect to any individual 
        admitted to such hospital after the end of such 3-month 
        period, or
          (B) within 6 months after the date the hospital is 
        found to be out of compliance with such requirements, 
        no payment may be made under this title with respect to 
        any individual in the hospital until the Secretary 
        finds that the hospital is in compliance with the 
        requirements of this title.
  (j) Enrollment Process for Providers of Services and 
Suppliers.--
          (1) Enrollment process.--
                  (A) In general.--The Secretary shall 
                establish by regulation a process for the 
                enrollment of providers of services and 
                suppliers under this title. Such process shall 
                include screening of providers and suppliers in 
                accordance with paragraph (2), a provisional 
                period of enhanced oversight in accordance with 
                paragraph (3), disclosure requirements in 
                accordance with paragraph (5), the imposition 
                of temporary enrollment moratoria in accordance 
                with paragraph (7), and the establishment of 
                compliance programs in accordance with 
                paragraph (9).
                  (B) Deadlines.--The Secretary shall establish 
                by regulation procedures under which there are 
                deadlines for actions on applications for 
                enrollment (and, if applicable, renewal of 
                enrollment). The Secretary shall monitor the 
                performance of medicare administrative 
                contractors in meeting the deadlines 
                established under this subparagraph.
                  (C) Consultation before changing provider 
                enrollment forms.--The Secretary shall consult 
                with providers of services and suppliers before 
                making changes in the provider enrollment forms 
                required of such providers and suppliers to be 
                eligible to submit claims for which payment may 
                be made under this title.
          (2) Provider screening.--
                  (A) Procedures.--Not later than 180 days 
                after the date of enactment of this paragraph, 
                the Secretary, in consultation with the 
                Inspector General of the Department of Health 
                and Human Services, shall establish procedures 
                under which screening is conducted with respect 
                to providers of medical or other items or 
                services and suppliers under the program under 
                this title, the Medicaid program under title 
                XIX, and the CHIP program under title XXI.
                  (B) Level of screening.--The Secretary shall 
                determine the level of screening conducted 
                under this paragraph according to the risk of 
                fraud, waste, and abuse, as determined by the 
                Secretary, with respect to the category of 
                provider of medical or other items or services 
                or supplier. Such screening--
                          (i) shall include a licensure check, 
                        which may include such checks across 
                        States; and
                          (ii) may, as the Secretary determines 
                        appropriate based on the risk of fraud, 
                        waste, and abuse described in the 
                        preceding sentence, include--
                                  (I) a criminal background 
                                check;
                                  (II) fingerprinting;
                                  (III) unscheduled and 
                                unannounced site visits, 
                                including preenrollment site 
                                visits;
                                  (IV) database checks 
                                (including such checks across 
                                States); and
                                  (V) such other screening as 
                                the Secretary determines 
                                appropriate.
                  (C) Application fees.--
                          (i) Institutional providers.--Except 
                        as provided in clause (ii), the 
                        Secretary shall impose a fee on each 
                        institutional provider of medical or 
                        other items or services or supplier 
                        (such as a hospital or skilled nursing 
                        facility) with respect to which 
                        screening is conducted under this 
                        paragraph in an amount equal to--
                                  (I) for 2010, $500; and
                                  (II) for 2011 and each 
                                subsequent year, the amount 
                                determined under this clause 
                                for the preceding year, 
                                adjusted by the percentage 
                                change in the consumer price 
                                index for all urban consumers 
                                (all items; United States city 
                                average) for the 12-month 
                                period ending with June of the 
                                previous year.
                          (ii) Hardship exception; waiver for 
                        certain medicaid providers.--The 
                        Secretary may, on a case-by-case basis, 
                        exempt a provider of medical or other 
                        items or services or supplier from the 
                        imposition of an application fee under 
                        this subparagraph if the Secretary 
                        determines that the imposition of the 
                        application fee would result in a 
                        hardship. The Secretary may waive the 
                        application fee under this subparagraph 
                        for providers enrolled in a State 
                        Medicaid program for whom the State 
                        demonstrates that imposition of the fee 
                        would impede beneficiary access to 
                        care.
                          (iii) Use of funds.--Amounts 
                        collected as a result of the imposition 
                        of a fee under this subparagraph shall 
                        be used by the Secretary for program 
                        integrity efforts, including to cover 
                        the costs of conducting screening under 
                        this paragraph and to carry out this 
                        subsection and section 1128J.
                  (D) Application and enforcement.--
                          (i) New providers of services and 
                        suppliers.--The screening under this 
                        paragraph shall apply, in the case of a 
                        provider of medical or other items or 
                        services or supplier who is not 
                        enrolled in the program under this 
                        title, title XIX, or title XXI as of 
                        the date of enactment of this 
                        paragraph, on or after the date that is 
                        1 year after such date of enactment.
                          (ii) Current providers of services 
                        and suppliers.--The screening under 
                        this paragraph shall apply, in the case 
                        of a provider of medical or other items 
                        or services or supplier who is enrolled 
                        in the program under this title, title 
                        XIX, or title XXI as of such date of 
                        enactment, on or after the date that is 
                        2 years after such date of enactment.
                          (iii) Revalidation of enrollment.--
                        Effective beginning on the date that is 
                        180 days after such date of enactment, 
                        the screening under this paragraph 
                        shall apply with respect to the 
                        revalidation of enrollment of a 
                        provider of medical or other items or 
                        services or supplier in the program 
                        under this title, title XIX, or title 
                        XXI.
                          (iv) Limitation on enrollment and 
                        revalidation of enrollment.--In no case 
                        may a provider of medical or other 
                        items or services or supplier who has 
                        not been screened under this paragraph 
                        be initially enrolled or reenrolled in 
                        the program under this title, title 
                        XIX, or title XXI on or after the date 
                        that is 3 years after such date of 
                        enactment.
                  (E) Use of information from the department of 
                treasury concerning tax debts.--In reviewing 
                the application of a provider of services or 
                supplier to enroll or reenroll under the 
                program under this title, the Secretary shall 
                take into account the information supplied by 
                the Secretary of the Treasury pursuant to 
                section 6103(l)(22) of the Internal Revenue 
                Code of 1986, in determining whether to deny 
                such application or to apply enhanced oversight 
                to such provider of services or supplier 
                pursuant to paragraph (3) if the Secretary 
                determines such provider of services or 
                supplier owes such a debt.
                  (F) Expedited rulemaking.--The Secretary may 
                promulgate an interim final rule to carry out 
                this paragraph.
          (3) Provisional period of enhanced oversight for new 
        providers of services and suppliers.--
                  (A) In general.--The Secretary shall 
                establish procedures to provide for a 
                provisional period of not less than 30 days and 
                not more than 1 year during which new providers 
                of medical or other items or services and 
                suppliers, as the Secretary determines 
                appropriate, including categories of providers 
                or suppliers, would be subject to enhanced 
                oversight, such as prepayment review and 
                payment caps, under the program under this 
                title, the Medicaid program under title XIX. 
                and the CHIP program under title XXI.
                  (B) Implementation.--The Secretary may 
                establish by program instruction or otherwise 
                the procedures under this paragraph.
          (4) 90-day period of enhanced oversight for initial 
        claims of dme suppliers.--For periods beginning after 
        January 1, 2011, if the Secretary determines that there 
        is a significant risk of fraudulent activity among 
        suppliers of durable medical equipment, in the case of 
        a supplier of durable medical equipment who is within a 
        category or geographic area under title XVIII 
        identified pursuant to such determination and who is 
        initially enrolling under such title, the Secretary 
        shall, notwithstanding sections 1816(c), 1842(c), and 
        1869(a)(2), withhold payment under such title with 
        respect to durable medical equipment furnished by such 
        supplier during the 90-day period beginning on the date 
        of the first submission of a claim under such title for 
        durable medical equipment furnished by such supplier.
          (5) Increased disclosure requirements.--
                  (A) Disclosure.--A provider of medical or 
                other items or services or supplier who submits 
                an application for enrollment or revalidation 
                of enrollment in the program under this title, 
                title XIX, or title XXI on or after the date 
                that is 1 year after the date of enactment of 
                this paragraph shall disclose (in a form and 
                manner and at such time as determined by the 
                Secretary) any current or previous affiliation 
                (directly or indirectly) with a provider of 
                medical or other items or services or supplier 
                that has uncollected debt, has been or is 
                subject to a payment suspension under a Federal 
                health care program (as defined in section 
                1128B(f)), has been excluded from participation 
                under the program under this title, the 
                Medicaid program under title XIX, or the CHIP 
                program under title XXI, or has had its billing 
                privileges denied or revoked.
                  (B) Authority to deny enrollment.--If the 
                Secretary determines that such previous 
                affiliation poses an undue risk of fraud, 
                waste, or abuse, the Secretary may deny such 
                application. Such a denial shall be subject to 
                appeal in accordance with paragraph (7).
          (6) Authority to adjust payments of providers of 
        services and suppliers with the same tax identification 
        number for medicare obligations.--
                  (A) In general.--Notwithstanding any other 
                provision of this title, in the case of an 
                applicable provider of services or supplier, 
                the Secretary may make any necessary 
                adjustments to payments to the applicable 
                provider of services or supplier under the 
                program under this title in order to satisfy 
                any amount described in subparagraph (B)(ii) 
                due from such obligated provider of services or 
                supplier.
                  (B) Definitions.--In this paragraph:
                          (i) In general.--The term 
                        ``applicable provider of services or 
                        supplier'' means a provider of services 
                        or supplier that has the same taxpayer 
                        identification number assigned under 
                        section 6109 of the Internal Revenue 
                        Code of 1986 as is assigned to the 
                        obligated provider of services or 
                        supplier under such section, regardless 
                        of whether the applicable provider of 
                        services or supplier is assigned a 
                        different billing number or national 
                        provider identification number under 
                        the program under this title than is 
                        assigned to the obligated provider of 
                        services or supplier.
                          (ii) Obligated provider of services 
                        or supplier.--The term ``obligated 
                        provider of services or supplier'' 
                        means a provider of services or 
                        supplier that owes an amount that is 
                        more than the amount required to be 
                        paid under the program under this title 
                        (as determined by the Secretary).
          (7) Temporary moratorium on enrollment of new 
        providers; nonpayment.--
                  (A) In general.--The Secretary may impose a 
                temporary moratorium on the enrollment of new 
                providers of services and suppliers, including 
                categories of providers of services and 
                suppliers, in the program under this title, 
                under the Medicaid program under title XIX, or 
                under the CHIP program under title XXI if the 
                Secretary determines such moratorium is 
                necessary to prevent or combat fraud, waste, or 
                abuse under either such program.
                  (B) Limitation on review.--There shall be no 
                judicial review under section 1869, section 
                1878, or otherwise, of a temporary moratorium 
                imposed under subparagraph (A).
                  (C) Nonpayment.--
                          (i) In general.--No payment may be 
                        made under this title or under a 
                        program described in subparagraph (A) 
                        with respect to an item or service 
                        described in clause (ii) furnished on 
                        or after October 1, 2017.
                          (ii) Item or service described.--An 
                        item or service described in this 
                        clause is an item or service 
                        furnished--
                                  (I) within a geographic area 
                                with respect to which a 
                                temporary moratorium imposed 
                                under subparagraph (A) is in 
                                effect; and
                                  (II) by a provider of 
                                services or supplier that meets 
                                the requirements of clause 
                                (iii).
                          (iii) Requirements.--For purposes of 
                        clause (ii), the requirements of this 
                        clause are that a provider of services 
                        or supplier--
                                  (I) enrolls under this title 
                                on or after the effective date 
                                of such temporary moratorium; 
                                and
                                  (II) is within a category of 
                                providers of services and 
                                suppliers (as described in 
                                subparagraph (A)) subject to 
                                such temporary moratorium.
                          (iv) Prohibition on charges for 
                        specified items or services.--In no 
                        case shall a provider of services or 
                        supplier described in clause (ii)(II) 
                        charge an individual or other person 
                        for an item or service described in 
                        clause (ii) furnished on or after 
                        October 1, 2017, to an individual 
                        entitled to benefits under part A or 
                        enrolled under part B or an individual 
                        under a program specified in 
                        subparagraph (A).
          (8) Compliance programs.--
                  (A) In general.--On or after the date of 
                implementation determined by the Secretary 
                under subparagraph (C), a provider of medical 
                or other items or services or supplier within a 
                particular industry sector or category shall, 
                as a condition of enrollment in the program 
                under this title, title XIX, or title XXI, 
                establish a compliance program that contains 
                the core elements established under 
                subparagraph (B) with respect to that provider 
                or supplier and industry or category.
                  (B) Establishment of core elements.--The 
                Secretary, in consultation with the Inspector 
                General of the Department of Health and Human 
                Services, shall establish core elements for a 
                compliance program under subparagraph (A) for 
                providers or suppliers within a particular 
                industry or category.
                  (C) Timeline for implementation.--The 
                Secretary shall determine the timeline for the 
                establishment of the core elements under 
                subparagraph (B) and the date of the 
                implementation of subparagraph (A) for 
                providers or suppliers within a particular 
                industry or category. The Secretary shall, in 
                determining such date of implementation, 
                consider the extent to which the adoption of 
                compliance programs by a provider of medical or 
                other items or services or supplier is 
                widespread in a particular industry sector or 
                with respect to a particular provider or 
                supplier category.
          (9) Hearing rights in cases of denial or non-
        renewal.--A provider of services or supplier whose 
        application to enroll (or, if applicable, to renew 
        enrollment) under this title is denied may have a 
        hearing and judicial review of such denial under the 
        procedures that apply under subsection (h)(1)(A) to a 
        provider of services that is dissatisfied with a 
        determination by the Secretary.
  (k) Quality Reporting by Cancer Hospitals.--
          (1) In general.--For purposes of fiscal year 2014 and 
        each subsequent fiscal year, a hospital described in 
        section 1886(d)(1)(B)(v) shall submit data to the 
        Secretary in accordance with paragraph (2) with respect 
        to such a fiscal year.
          (2) Submission of quality data.--For fiscal year 2014 
        and each subsequent fiscal year, each hospital 
        described in such section shall submit to the Secretary 
        data on quality measures specified under paragraph (3). 
        Such data shall be submitted in a form and manner, and 
        at a time, specified by the Secretary for purposes of 
        this subparagraph.
          (3) Quality measures.--
                  (A) In general.--Subject to subparagraph (B), 
                any measure specified by the Secretary under 
                this paragraph must have been endorsed by the 
                entity with a contract under section 1890(a).
                  (B) Exception.--In the case of a specified 
                area or medical topic determined appropriate by 
                the Secretary for which a feasible and 
                practical measure has not been endorsed by the 
                entity with a contract under section 1890(a), 
                the Secretary may specify a measure that is not 
                so endorsed as long as due consideration is 
                given to measures that have been endorsed or 
                adopted by a consensus organization identified 
                by the Secretary.
                  (C) Time frame.--Not later than October 1, 
                2012, the Secretary shall publish the measures 
                selected under this paragraph that will be 
                applicable with respect to fiscal year 2014.
          (4) Public availability of data submitted.--The 
        Secretary shall establish procedures for making data 
        submitted under paragraph (4) available to the public. 
        Such procedures shall ensure that a hospital described 
        in section 1886(d)(1)(B)(v) has the opportunity to 
        review the data that is to be made public with respect 
        to the hospital prior to such data being made public. 
        The Secretary shall report quality measures of process, 
        structure, outcome, patients' perspective on care, 
        efficiency, and costs of care that relate to services 
        furnished in such hospitals on the Internet website of 
        the Centers for Medicare & Medicaid Services.

           *       *       *       *       *       *       *




                             MINORITY VIEWS

                              Introduction

    Workplace violence is a risk in the health care and social 
service industries; the Bureau of Labor Statistics (BLS) 
reported those industries experience the highest rates of 
injuries caused by workplace violence. Additionally, BLS 
reported health care and social service workers suffered 71 
percent of all workplace violence injuries caused by persons in 
2017 and are more than four times as likely to suffer a 
workplace violence injury than workers overall. Committee 
Republicans are committed to responsible federal laws, 
regulations and policies which help ensure American workers are 
kept out of harm's way on the job so they can return home to 
their families every day healthy and safe.
    However, H.R. 1309, the Workplace Violence Prevention for 
Health Care and Social Service Workers Act, is not the right 
solution to address workplace violence in the health care and 
social services industries. The legislation is overly 
prescriptive, limits the Occupational Safety and Health 
Administration's (OSHA) ability to write an effective, 
workable, and feasible regulation, and imposes unwarranted 
shortcuts in the regulatory process that will result in a lack 
of meaningful and important stakeholder input. Despite scant 
progress on workplace violence in the health care and social 
service industries during the Obama administration, OSHA has 
recognized the challenges these industries face and is moving 
forward with the rulemaking process.\1\ H.R. 1309 halts that 
rulemaking process and limits the agency's ability to write a 
responsive, appropriate, and protective rule.
---------------------------------------------------------------------------
    \1\Office of Info. & Reg. Affairs, Prevention of Workplace Violence 
in Health Care and Social Assistance, Regulatory Agenda (2019).
---------------------------------------------------------------------------
    Committee Republicans believe there can be a bipartisan 
solution to this issue that would aid in the rulemaking process 
and provide protection to health care and social service 
workers. However, by advancing H.R. 1309, the Committee 
majority is short-circuiting the regulatory process and is 
choosing to push through mandated requirements that lack 
important and meaningful stakeholder input. For these reasons, 
and as set forth more fully below, Committee Republicans are 
opposed to H.R. 1309.

                        CONCERNS WITH H.R. 1309

H.R. 1309 Evades Important Regulatory Steps
    H.R. 1309 requires OSHA to circumvent traditional and long-
standing rulemaking procedures under the Occupational Safety 
and Health Act of 1970 (OSH Act) and the Administrative 
Procedure Act. The bill compels OSHA to complete and issue an 
interim final standard within one year of enactment and with 
only one limited public comment period of 30 days prior to 
publication of the interim final standard. As such, H.R. 1309 
severely limits the participation of industry, worker 
representatives, the scientific community, and the public in 
the development of a new comprehensive standard governing a 
complex and highly technical area of workplace safety.
    In 2015, then-Assistant Secretary of Occupational Safety 
and Heath David Michaels testified before the Committee 
outlining the important, necessary steps in developing a safety 
and health regulation:

          Developing OSHA regulations is a complex and long 
        process, with extensive public consultation before any 
        new standards are issued including, depending on the 
        standard, requests for information, stakeholder 
        meetings, Small Business Regulatory Enforcement and 
        Fairness Act (SBREFA) panels, public hearings, and pre- 
        and post-hearing comment periods. We are required by 
        law to ensure that our standards are economically and 
        technically feasible.\2\
---------------------------------------------------------------------------
    \2\Protecting America's Workers: An Enforcement Update from the 
Occupational Safety and Health Administration: Hearing Before the 
Subcomm. on Workforce Protections of the H. Comm. on Educ. & the 
Workforce, 114th Cong. 11-12 (2015) (statement of David Michaels, 
Assistant Sec'y, Occupational Safety & Health Admin., U.S. Dep't of 
Labor).

    H.R. 1309 forces the agency to skip these important steps, 
as OSHA is required to complete an interim final standard 
within one year. If the agency does not complete the 
promulgation of a standard within one year, then the provisions 
of the bill go into effect. Therefore, the agency would be 
enforcing an interim final standard that lacks any public 
feedback. The regulatory steps Dr. Michaels outlined are 
necessary for a variety of important reasons including allowing 
the agency to gather important feedback from the public in 
order to create the most protective, workable and feasible 
federal safety and health standards possible.
    For example, one vital step the bill omits is the SBREFA 
panel. Eric Hobbs, an attorney with expertise in workplace 
safety and health, testified in 2018 on the importance of the 
SBREFA panel:

          Under the panel review process, small businesses who 
        would be affected by a proposed regulation are allowed 
        to review the draft proposal as well as OSHA's draft 
        impact assessment and provide direct comments on them. 
        This happens at a stage in the process when there is 
        still time to make adjustments--unlike when, by 
        contrast, a proposed regulation has been issued and 
        there is very little chance to make significant 
        changes.\3\
---------------------------------------------------------------------------
    \3\A More Effective and Collaborative OSHA: A View from 
Stakeholders: Hearing before the Subcomm. on Workforce Protections of 
the H. Comm. on Educ. & the Workforce, 115th Cong. (2018) (written 
statement of Eric Hobbs, Shareholder, Ogletree, Deakins, at 4).

    Notably, H.R. 1309 does not consider the impact of a 
workplace violence standard on small businesses and does not 
require an economic impact test to see if it will have a 
significant impact on small businesses or if there are ways to 
minimize the impact.\4\ The regulatory steps to create a 
federal safety and health standard are vital to ensure the 
scope of the standard is appropriate, as small businesses may 
not have the same risk of workplace violence, or the same 
challenges, as larger employers. During the Obama 
administration, OSHA stated in its 2016 request for information 
(RFI) that if the agency moves forward in the rulemaking 
process it will consider the impacts on small businesses: 
``Regardless of the significance of the impacts, OSHA seeks 
ways of minimizing the burdens of small businesses consistent 
with OSHA's statutory and regulatory requirements and 
objectives.''\5\
---------------------------------------------------------------------------
    \4\Notably, the California Division of Occupational Safety and 
Health's workplace violence prevention standard, which served as a 
model for H.R. 1309, has a narrower scope than H.R. 1309, and therefore 
it is not well-suited to inform what is feasible for small employers, 
as has been suggested by supporters of the legislation.
    \5\Prevention of Workplace Violence for Healthcare and Social 
Assistance, 81 Fed. Reg. 88,147, 88,164 (Dec. 7, 2016) (request for 
information).
---------------------------------------------------------------------------
    Mr. Manesh Rath, an attorney with experience in 
occupational safety and health law and administrative law, 
discussed in his testimony before the Committee why Congress 
would not be justified in skipping regulatory steps with 
respect to a workplace violence standard in healthcare:

          Congress is empowered to instruct an agency to skip 
        this important element of procedural fairness by 
        enacting its own standard, but Congress should exercise 
        that prerogative with caution and infrequently, and 
        only when (1) the issue is fully understood and the 
        remedy is obvious; or (2) there is a national emergency 
        such as an epidemic. Workplace violence for healthcare 
        workers does not meet either of those criteria.\6\
---------------------------------------------------------------------------
    \6\Caring for Our Caregivers: Protecting Health Care and Social 
Service Workers from Workplace Violence: Hearing Before the Subcomm. on 
Workforce Protections of the H. Comm. on Educ. & Labor, 116th Cong. 
(2019) (written statement of Manesh Rath, Partner, Keller & Heckman 
LLP, at 2) [hereinafter Rath Statement].

    In a letter to the Committee, the American Hospital 
Association also expressed concerns about omitting important 
regulatory steps:
          [B]ecause hospitals have already implemented 
        specifically tailored policies and programs to address 
        workplace violence, we do not believe that the OSHA 
        standards required by H.R. 1309 are warranted, nor do 
        we support an expedited approach that would deny the 
        public the opportunity to review and comment on 
        proposed regulations.\7\
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    \7\Letter from Thomas Nickels, Exec. Vice President, Am. Hosp. 
Ass'n, to Chairman Bobby Scott & Ranking Member Virginia Foxx (June 10, 
2019) (on file).

    H.R. 1309 also discounts the expertise of American workers 
who have experienced workplace violence and who could provide 
important insights, as well as experts who have been 
researching the issue for years. Mr. Rath discussed in his 
testimony that this is a subject area in which we have limited 
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knowledge:

          Any effort to regulate the issue of workplace 
        violence in healthcare should be thoughtful rather than 
        rushed. The process should be inclusive of employers, 
        employees, the security industry, the insurance 
        industry, and the scientific and medical professions. 
        This subcommittee can and should have faith that the 
        collaborative input of those with experience, training, 
        and learning in this field will yield a better approach 
        than the Bill before us today.\8\
---------------------------------------------------------------------------
    \8\Rath Statement, supra note 6, at 2.
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OSHA is Enforcing Workplace Violence Prevention
    OSHA is currently enforcing workplace violence prevention 
under the general duty clause, section 5(a)(1) of the OSH Act. 
Additionally, in 2017, OSHA issued an enforcement directive on 
conducting investigations and citations related to occupational 
exposure to workplace violence.\9\ Therefore, allowing OSHA to 
complete a comprehensive rulemaking process, rather than 
requiring a rushed, corner cutting approach mandated by H.R. 
1309, will not leave the health care and social services 
industry sectors without proper enforcement.
---------------------------------------------------------------------------
    \9\OSHA, Dir. No. CPL 02-01-058, Enforcement Procedures and 
Scheduling for Occupational Exposure to Workplace Violence (2017).
---------------------------------------------------------------------------
    For example, in 2019, the Occupational Safety and Health 
Review Commission (OSHRC) upheld penalties issued by OSHA under 
the general duty clause against health care facilities for not 
adequately addressing workplace violence. Covette Rooney, the 
chief administrative law judge of OSHRC, stated in her decision 
and order:

          There is no specific OSHA standard addressing the 
        hazard of workplace violence. This does not mean that 
        employers have no obligation to address the hazard. 
        Rather, if an employer or its industry recognize that 
        workplace violence is an actual or potential hazard 
        that can cause death or serious physical harm, the 
        Act's general duty clause requires such employers to 
        act to eliminate or materially reduce this hazard.\10\
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    \10\BHC Northwest Psychiatric Hospital LLC, OSHRC No. 17-0063 (Jan. 
22, 2019) (decision and order).

    As this OSHRC decision shows, OSHA is currently enforcing 
workplace violence successfully under the general duty clause, 
and rushing a standard through the regulatory process is 
unnecessary.
H.R. 1309 is Unreasonably and Unnecessarily Prescriptive
    H.R. 1309 requires OSHA to base its interim final standard 
on the 2015 OSHA ``Guidelines for Preventing Workplace Violence 
for Healthcare and Social Service Workers.''\11\ These 
voluntary guidelines were based on best practices at the time 
and feedback from stakeholders. However, the interim final 
standard as prescribed by H.R. 1309 will not consider any data, 
or lessons that have been learned since 2015 that are contrary 
to the 2015 guidance. H.R. 1309 thus disadvantages the very 
workers it purports to help by ignoring important feedback and 
information that is currently available. Mr. Rath stated in his 
testimony:
---------------------------------------------------------------------------
    \11\Workplace Violence Prevention for Health Care and Social 
Services Workers Act, H.R. 1309, 116th Cong. Sec. 101(a)(1)(B) (2019).

          Before proceeding to rulemaking to develop a legally 
        binding standard, OSHA should review its experience 
        with the guidance issued on workplace violence and what 
        has been learned from citing employers for workplace 
        violence hazards under the General Duty Clause.\12\
---------------------------------------------------------------------------
    \12\Rath, supra note 6, at 2.

    Moreover, in 2016, OSHA published an RFI on workplace 
violence prevention for health care and social assistance, but 
H.R. 1309 does not incorporate information and findings from 
the comments responding to the RFI which were received by 
OSHA.\13\ The sole purpose of an RFI is to gather data and 
information to help in determining the appropriate next steps 
in a rulemaking process; H.R. 1309 disregards this important 
step.
---------------------------------------------------------------------------
    \13\Prevention of Workplace Violence for Health Care and Social 
Assistance, 81 Fed. Reg. 88,147.
---------------------------------------------------------------------------
    In considering regulatory activity at the federal level, 
past experience should always help inform the most effective 
solution moving forward. In 2016, California finalized a 
regulation titled ``Violence Prevention in Health Care,'' which 
recently went into full effect in April 2018.\14\ When 
considering a far-reaching federal regulation on workplace 
violence prevention, it would be irresponsible not to review 
and study the California policy's impact on the regulated 
community. However, H.R. 1309 requires the final standard 
provide no less protection than any standard adopted by a state 
plan, essentially requiring OSHA to default to California's 
standard, which is purportedly the most comprehensive state 
standard on workplace violence prevention.
---------------------------------------------------------------------------
    \14\Cal. Code of Regs. tit. 8 Sec. 3342.
---------------------------------------------------------------------------
    H.R. 1309 does not take into consideration that 
California's standard may not be the most effective, workable, 
and feasible policy both in California and if it were to be 
imposed around the country. OSHA's 2016 RFI understood the 
importance of gathering information on state laws, stating: 
``OSHA is also interested in hearing about healthcare 
facilities' experiences with provisions of state laws that have 
been shown to be effective in some way.''\15\
---------------------------------------------------------------------------
    \15\Prevention of Workplace Violence for Healthcare and Social 
Assistance, 81 Fed. Reg. at 88,152.
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H.R. 1309 Lacks Needed Research and Data
    Committee Democrats have failed to provide the needed 
foundation for a workplace violence prevention standard 
required by H.R. 1309. Regulation of workplace violence 
prevention in the health care and social service industries 
must be grounded in evidence-based research. Currently, there 
is no agreed-upon set of policies to prevent workplace 
violence, and researchers in the field have pointed to the need 
for additional studies.
    The Centers for Disease Control and Prevention published 
its ``National Occupational Research Agenda for Healthcare and 
Social Assistance'' in February 2019. The research agenda was 
developed to identify the knowledge and actions most urgently 
needed to improve safety in the industry. The 2019 agenda 
included an objective to ``investigate the epidemiology of 
workplace violence in health care and identify effective 
strategies for prevention and mitigation.'' The objective 
points to the following concerns regarding needed research on 
the topic:

          Many existing studies have evaluated workplace 
        violence risk factors and prevention measures, but most 
        lack the comprehensive, facility- and work area-
        specific perspective that is needed to effectively 
        prevent workplace violence.
          Additionally, many of these studies examine the 
        effects of training programs, showing little impact on 
        workplace violence incident and injury rates.\16\
---------------------------------------------------------------------------
    \16\ Centers for Disease Control & Prevention, National 
Occupational Research Agenda for Healthcare and Social Assistance 13 
(Feb. 2019).

    Even the 2016 report by the Government Accountability 
Office (GAO), cited by supporters of H.R. 1309, highlighted the 
fact that there had been a limited number of studies on the 
effectiveness of workplace violence prevention, stating: 
Relatively few studies have been conducted on the effectiveness 
of workplace violence prevention programs, limiting what is 
known about the extent to which such programs or their 
components reduce workplace violence.\17\ Moreover, the 2016 
GAO report did not call on OSHA to promulgate a standard; 
instead it recommended a full assessment of OSHA's efforts to 
---------------------------------------------------------------------------
address workplace violence in health care facilities:

    \17\A U.S. Gov't Accountability Off., GAO-16-11, Workplace Safety 
and Health: Additional Efforts Needed to Help Protect Health Care 
Workers from Workplace Violence 1 (Mar. 2016).
---------------------------------------------------------------------------
          [OSHA should a]ssess the results of its efforts to 
        determine whether additional action, such as 
        development of a standard may be needed. OSHA has not 
        fully assessed the results of its efforts to address 
        workplace violence in health care facilities. Without 
        assessing these results, OSHA will not be in a position 
        to know whether its efforts are effective or if 
        additional action may be needed to address this 
        hazard.\18\
---------------------------------------------------------------------------
    \18\ Id.

    Following GAO's recommendation, as noted previously, OSHA 
issued an RFI to gather more data from the public to better 
---------------------------------------------------------------------------
understand how to proceed, stating:

          OSHA is interested in hearing from employers and 
        individuals in facilities that provide healthcare and 
        social assistance about their experience with the 
        various components of workplace violence prevention 
        programs that are currently being implemented by their 
        facilities.\19\
---------------------------------------------------------------------------
    \19\ Prevention of Workplace Violence for Healthcare and Social 
Assistance, 81 Fed. Reg. at 88,161.

    The RFI is only a first step for OSHA as it gathers 
important information on workplace violence prevention, and the 
agency clearly believed additional data was needed before 
proceeding. Members of the health care and social assistance 
research communities have identified workplace violence 
prevention as an area in need of further examination, yet the 
Committee majority is pushing through a standard that lacks 
meaningful expert input and stakeholder participation.

H.R. 1309 Inappropriately Imposes a New Government Enforcement Regime 
        on Employers

    It is important to protect employees from retaliation for 
reporting a violent incident or injury to their employer. That 
is why under section 11(c) of the OSH Act, employees have the 
right to pursue complaints alleging retaliation.\20\ However, 
H.R. 1309 allows government bureaucrats to investigate what 
they believe is potential retaliation in the absence of an 
actual complaint. The effect is to impose a whistleblower 
enforcement regime on employers without an actual whistleblower 
making a claim. Employees are protected from retaliation under 
current law, but H.R. 1309 inappropriately expands OSHA's 
authority to remedy alleged retaliation without a 
whistleblower. This would create two pathways to address 
alleged retaliation which could result in conflicting findings.
---------------------------------------------------------------------------
    \20\ 29 U.S.C. Sec. 660(c); OSHA's 2015 ``Guidelines for Preventing 
Workplace Violence for Healthcare and Social Service Workers,'' states:
---------------------------------------------------------------------------
        Section 11(c)(1) of the Act provides that ``No person 
      shall discharge or in any manner discriminate against any 
      employee because such employee has filed any complaint or 
      instituted or caused to be instituted any proceeding under 
      or related to this Act or has testified or is about to 
      testify in any such proceeding or because of the exercise 
      by such employee on behalf of himself or others of any 
      right afforded by this Act.''
Reprisal or discrimination against an employee for reporting an 
incident or injury related to workplace violence, related to this 
guidance, to an employer or OSHA would constitute a violation of 
Section 11(c) of the Act. In addition, 29 CFR 1904.36 provides that 
Section 11(c) of the Act prohibits discrimination against an employee 
for reporting a work related fatality, injury or illness.

H.R. 1309 Creates Data Privacy Risks and Requires Unnecessary Annual 
        Reporting to OSHA

    Employers use records, such as violent incident logs and 
annual summaries, to improve internal management and processes 
to protect their workplaces. Additionally, inspectors still 
have the right to review the records upon inspection of the 
facility.\21\ However, if employers are required to submit 
these reports to OSHA annually, as H.R. 1309 mandates, it will 
chill the use of the records for this purpose; the employer 
will have no guarantee the records will not be released either 
intentionally or unintentionally and used improperly. In a 
comment letter to OSHA regarding the proposed 2013 
recordkeeping submittal requirement, the Coalition for 
Workplace Safety stated:
---------------------------------------------------------------------------
    \21\29 U.S.C. 657.

          Public disclosure of this information will lead to 
        underreporting of injuries and illness, creating a 
        problem that does not currently exist. And, it will 
        allow those who wish to do so, to mischaracterize and 
        misuse the information for reasons wholly unrelated to 
        safety.\22\
---------------------------------------------------------------------------
    \22\ Letter from Coalition for Workplace Safety to David Michaels, 
Assistant Sec'y, Occupational Safety & Health Admin., U.S. Dep't of 
Labor (Mar. 10, 2014), https://www.regulations.gov/
document?D=OSHA_2013_0023_1411.

    It is important that facilities keep accurate records of 
incidents, responses to incidents, and annual data, but 
providing it to OSHA annually will not produce greater safety 
benefits.

                         Republican Substitute

    Committee Republicans are committed to ensuring that health 
care and social service workers are protected from workplace 
violence and are supportive of OSHA's efforts to promulgate a 
rule on workplace violence prevention. However, Congress should 
aid in the rulemaking process and not circumvent it.
    To achieve these goals, Representative Bradley Byrne (R-AL) 
offered an amendment in the nature of a substitute at the 
Committee markup that requires the Secretary of Labor to 
promulgate a final standard on workplace violence prevention 
for health care and social service sectors that allows OSHA to 
follow the proper rulemaking procedures and ultimately be 
responsive to public comments. The amendment strikes the 
requirement to publish an interim final standard within an 
arbitrary deadline of one year. Instead, the amendment allows 
the agency to do its due diligence to develop a standard based 
on meaningful and robust public comments. The amendment 
outlines principles of what a workplace violence prevention 
standard should look like, and it allows the agency to be 
responsive to experts and public concerns in order to produce 
the most protective and feasible standard.
    Representative Byrne's amendment also requires that OSHA 
conduct an educational campaign on workplace violence 
prevention for health care and social service industries while 
it is engaged in rulemaking. The campaign will help raise 
awareness of the issue, resulting in increased compliance and 
wider participation in the rulemaking process. In addition, 
when OSHA promulgates the workplace violence prevention 
standard, the agency is required to conduct an educational 
campaign for covered employees and employers on the 
requirements of the final standard.
    In addition, the amendment removes the annual reporting 
requirement of workplace violence data to OSHA, does not allow 
anti-retaliation investigations that are not based on a 
complaint, and maintains the current anti-retaliation provision 
in the OSH Act. Unfortunately, Committee Democrats, by 
unanimously opposing this amendment, chose to prejudge and 
impose a prescriptive solution without allowing for meaningful 
stakeholder input, which will result in a flawed regulatory 
approach.

                               Conclusion

    H.R. 1309 ignores expert and practical input and imposes 
mandates that may ultimately harm the very people the 
legislation intends to protect. H.R. 1309 forecloses on better, 
more protective and feasible solutions that would result from 
the established rulemaking process. H.R 1309 fails to allow 
public input that will produce better and more protective 
solutions to workplace violence prevention and imposes specific 
requirements on regulated entities without providing supporting 
evidence to demonstrate that this government intervention will 
work. For these reasons, and those outlined above, Committee 
Republicans oppose enactment of H.R. 1309 as reported by the 
Committee on Education and Labor.

                                   Virginia Foxx,
                                           Ranking Member.
                                   Glenn ``GT'' Thompson.
                                   Tim Walberg.
                                   Brett Guthrie.
                                   Bradley Byrne.
                                   Glenn Grothman.
                                   Rick W. Allen.
                                   Lloyd Smucker.
                                   Jim Banks.
                                   Mark Walker.
                                   James Comer.
                                   Russ Fulcher.
                                   Van Taylor.
                                   Steve C. Watkins, Jr.
                                   Ron Wright.
                                   Daniel Meuser.
                                   Dusty Johnson.
                                   Fred Keller.
                                   Gregory F. Murphy.