; or (ii) add minimum direct care registered nurse-to-patient ratios for units not referred to in paragraphs (1) and (2). (B) Consultation Such regulations shall be prescribed after consultation with affected hospitals and registered nurses. (6) Ancillary and additional staffing (A) In general The Secretary may prescribe regulations requiring additional staffing of direct care registered nurses, licensed vocational or practice nurses, licensed psychiatric technicians, certified nursing or patient care assistants, or other licensed or unlicensed ancillary staff above the minimum registered nurse-to-patient ratios that is based on the assessment of the individual patient’s nursing care needs, the individual patient’s nursing care plan, and acuity level. (B) Consultation Such regulations shall be prescribed after consultation with affected hospitals, registered nurses, and ancillary staff. (7) Relationship to state-imposed ratios Nothing in this title shall preempt State standards that the Secretary determines to be as stringent as Federal requirements for a staffing plan established under this title. Minimum direct care registered nurse-to-patient ratios established under this subsection shall not preempt State requirements that the Secretary determines are as stringent as to Federal requirements for direct care registered nurse-to-patient ratios established under this title. (8) Exemption in emergencies The requirements established under this subsection shall not apply during a state of emergency if a hospital is requested or expected to provide an exceptional level of emergency or other medical services. If a hospital seeks to apply the exemption under this paragraph in response to a complaint filed against the hospital for a violation of the provisions of this title, the hospital must demonstrate that prompt and diligent efforts were made to maintain required staffing levels. The Secretary shall issue guidance to hospitals that describes situations that constitute a state of emergency for purposes of the