HB 1117

1	A bill to be entitled
2	An act relating to the staffing of health care facilities;
3	creating ss. 395.051-395.057, F.S.; providing a popular
4	name; providing legislative findings; defining terms;
5	prescribing safe staffing standards for health care
6	facilities; requiring licensed facilities to submit an
7	annual staffing plan to the Agency for Health Care
8	Administration; providing standards for the required skill
9	mix; requiring compliance with the staffing plan;
10	requiring recordkeeping; prohibiting mandatory overtime;
11	providing applicability; providing to employees the right
12	to refuse certain assignments and the right to report
13	suspected violations of safe staffing standards; providing
14	for the agency to enforce compliance with the act;
15	requiring the agency to develop and adopt rules; providing
16	an effective date.
17
18	Be It Enacted by the Legislature of the State of Florida:
19
20	Section 1.  Section 395.051, Florida Statutes, is created
21	to read:
22	395.051  Popular name.--Sections 395.051-395.057 may be
23	cited as the "Safe Staffing for Quality Care Act."
24	Section 2.  Section 395.052, Florida Statutes, is created
25	to read:
26	395.052  Legislative findings.--The Legislature finds that:
27	(1)  The state has a substantial interest in ensuring that
28	delivery of health care services to patients in health care
29	facilities located in this state is adequate and safe and that
30	health care facilities retain sufficient nursing staff so as to
31	promote optimal health care outcomes.
32	(2)  Recent changes in the state's health care delivery
33	system are resulting in a higher acuity level among patients in
34	health care facilities.
35	(3)  Registered nurses constitute the highest percentage of
36	direct health care staff in acute care facilities and have a
37	central role in delivering health care.
38	(4)  Extensive research indicates that inadequate
39	registered nurse staffing in hospitals can result in increased
40	patient death rates, dangerous medical errors, and increased
41	length of stay.
42	(5)  To ensure adequate protection and care for patients in
43	health care facilities, it is essential that qualified
44	registered nurses who are trained and authorized to deliver
45	nursing services be accessible and available to meet the nursing
46	needs of patients.
47	Section 3.  Section 395.053, Florida Statutes, is created
48	to read:
49	395.053  Definitions.--As used in this act, the term:
50	(1)  "Acuity system" means an established measurement
51	instrument that:
52	(a)  Predicts nursing care requirements for individual
53	patients based on the severity of patient illness, the need for
54	specialized equipment and technology, the intensity of nursing
55	interventions required, and the complexity of clinical nursing
56	judgment needed to design, implement, and evaluate the patient's
57	nursing care plan.
58	(b)  Details the amount of nursing care needed, both in the
59	number of registered nurses and in the skill mix of nursing
60	personnel required daily for each patient in a nursing
61	department or unit.
62	(c)  Is stated in terms that can be readily used and
63	understood by direct-care nursing staff.
64	(2)  "Assessment tool" means a measurement system that
65	compares the staffing level in each nursing department or unit
66	against actual patient nursing care requirements in order to
67	review the accuracy of an acuity system.
68	(3)  "Declared state of emergency" means an officially
69	designated state of emergency which has been declared by a
70	federal, state, or local government official who has the
71	authority to declare that the state, county, municipality, or
72	locality is in a state of emergency. The term does not include a
73	state of emergency which results from a labor dispute in the
74	health care industry.
75	(4)  "Direct-care nurse" or "direct-care nursing staff"
76	means any registered nurse who has direct responsibility to
77	oversee or carry out medical regimens or nursing care for one or
78	more patients. A nurse administrator, nurse supervisor, nurse
79	educator, charge nurse, or other registered nurse who does not
80	have a specific patient assignment may not be included in the
81	calculation of the registered nurse-to-patient ratio.
82	(5)  "Documented staffing plan" means a detailed written
83	plan that sets forth the minimum number, skill mix, and
84	classification of licensed nurses required in each nursing
85	department or unit in the health care facility for a given year,
86	based on reasonable projections derived from the patient census
87	and average acuity level within each department or unit during
88	the previous year, the department or unit size and geography,
89	the nature of services provided, and any foreseeable changes in
90	department or unit size or function during the current year.
91	(6)  "Health care facility" means an acute care hospital,
92	emergency care hospital, or ambulatory surgical center licensed
93	under chapter 395, an outpatient surgical facility, or a
94	psychiatric treatment facility licensed under chapter 394.
95	(7)  "Nurse" means a registered nurse.
96	(8)  "Nursing care" means care that falls within the scope
97	of practice set forth in chapter 464 and other laws and rules or
98	care that is otherwise encompassed within recognized
99	professional standards of nursing practice, including
100	assessment, nursing diagnosis, planning, intervention,
101	evaluation, and patient advocacy.
102	(9)  "On-call time" means time spent by an employee who:
103	(a)  Is not working on the premises of the place of
104	employment but who is compensated for availability; or
105	(b)  As a condition of employment, has agreed to be
106	available to return to the premises of the place of employment
107	on short notice if the need arises.
108	(10)  "Overtime" means the hours worked in excess of any of
109	the following:
110	(a)  An agreed-upon, predetermined, regularly scheduled
111	shift;
112	(b)  Twelve hours in a 24-hour period; or
113	(c)  Eighty hours in a consecutive 14-day period.
114	(11)  "Reasonable efforts," in reference to the prohibition
115	on mandatory overtime, means that the employer is unable to
116	obtain staff coverage even though the employer has:
117	(a)  Sought, from among all available qualified staff who
118	are working, individuals who would volunteer to work overtime.
119	(b)  Contacted employees who have made themselves available
120	to work overtime.
121	(c)  Sought the use of per diem staff.
122	(d)  Sought personnel from a contracted temporary agency if
123	such staffing is permitted by law or an applicable collective
124	bargaining agreement.
125	(12)  "Skill mix" means the differences in licensing,
126	specialty, and experience among direct-care nurses.
127	(13)  "Staffing level" means the actual numerical
128	registered nurse-to-patient ratio within a nursing department or
129	unit.
130	(14)  "Unforeseeable emergent circumstance" means:
131	(a)  An unforeseen declared national, state, or municipal
132	emergency;
133	(b)  A situation in which a health care disaster plan is
134	activated; or
135	(c)  An unforeseen disaster or other catastrophic event
136	that substantially affects or increases the need for health care
137	services.
138	Section 4.  Section 395.054, Florida Statutes, is created
139	to read:
140	395.054  Facility staffing standards.--
141	(1)  STAFFING PRINCIPLES.--The basic principles of staffing
142	in health care facilities should be focused on patient health
143	care needs and based on consideration of patient acuity levels
144	and services that need to be provided to ensure optimal
145	outcomes. Safe staffing practices recognize the importance of
146	all health care workers in providing quality patient care. The
147	setting of staffing standards for registered nurses is not to be
148	interpreted as justifying the understaffing of other critical
149	health care workers, including licensed practical nurses, social
150	workers, and other licensed or unlicensed assistive personnel.
151	Indeed, the availability of these other health care workers
152	enables registered nurses to focus on the nursing care functions
153	that only registered nurses, by law, are permitted to perform
154	and thereby helps to ensure adequate staffing levels.
155	(2)  SPECIFIC STANDARDS.--Health care facilities shall
156	provide staffing by registered nurses in accordance with the
157	minimum nurse-to-patient ratios that are set forth in this
158	subsection. Staffing for care that does not require a registered
159	nurse is not included within these ratios and must be determined
160	pursuant to the patient classification system. Nurse-to-patient
161	ratios represent the maximum number of patients which are
162	assigned to one registered nurse during one shift. Only nurses
163	providing direct patient care shall be included in the ratios.
164	Nurse administrators, nurse supervisors, charge nurses, and
165	other licensed nurses who do not have a specific patient care
166	assignment may not be included in the calculation of the nurse-
167	to-patient ratio. This section does not prohibit a registered
168	nurse from providing care within the scope of his or her
169	practice to a patient assigned to another nurse.
170	(a)  No more than two patients may be assigned to each
171	registered nurse in a critical care unit, so that the minimum
172	registered nurse-to-patient ratio is 1 to 2 or fewer at any
173	time. As used in this act, the term "critical care unit" means a
174	nursing unit of a general acute care hospital that provides one
175	of the following services: an intensive care service, a
176	postanesthesia recovery service, a burn center service, a
177	coronary care service, or an acute respiratory service. In a
178	neonatal intensive care service, no more than two patients may
179	be assigned to each nurse.
180	(b)  In a surgical service operating room, no more than one
181	patient-occupied operating room may be assigned to each
182	registered nurse.
183	(c)  No more than two patients may be assigned to each
184	registered nurse in a labor/delivery unit of a perinatal
185	service, so that the registered nurse-to-patient ratio is 1 to 2
186	or fewer at any time.
187	(d)  No more than three mother-baby couplets may be
188	assigned to each registered nurse in a postpartum area of a
189	perinatal unit at any time. If multiple births have occurred,
190	the total number of mothers plus infants which are assigned to a
191	single registered nurse may not exceed six.
192	(e)  In a hospital that provides basic emergency medical
193	services or comprehensive emergency medical services, no more
194	than three patients who are receiving emergency services may be
195	assigned to each registered nurse, so that the registered nurse-
196	to-patient ratio in an emergency department is 1 to 3 or fewer
197	at any time patients are receiving treatment. No fewer than two
198	registered nurses must be physically present in the emergency
199	department when a patient is present.
200	(f)  The nurse assigned to triage patients may not have a
201	patient assignment, may not be assigned the responsibility for
202	the base ratio, and may not be counted in the registered nurse-
203	to-patient ratio.
204	(g)  When nursing staff are attending critical care
205	patients in the emergency department, no more than two patients
206	may be assigned to each registered nurse. When nursing staff in
207	the emergency department are attending trauma patients, no more
208	than one patient may be assigned to each registered nurse at any
209	time.
210	(h)  No more than three patients may be assigned to each
211	registered nurse in a step-down unit, so that the minimum
212	registered nurse-to-patient ratio is 1 to 3 or fewer at any
213	time. As used in this subsection, the term:
214	1.  "Artificial life support" means a system that uses
215	medical technology to aid, support, or replace a vital function
216	of the body which has been seriously damaged.
217	2.  "Step-down unit" means a unit that is organized,
218	operated, and maintained to provide for the monitoring and care
219	of patients who have moderate or potentially severe physiologic
220	instability that requires technical support but not necessarily
221	artificial life support.
222	3.  "Technical support" means specialized equipment or
223	personnel, or both, that provides for invasive monitoring,
224	telemetry, and mechanical ventilation for the immediate
225	amelioration or remediation of severe pathology for those
226	patients who require less care than intensive care but more than
227	that which is available from medical/surgical care.
228	(i)  No more than three patients may be assigned to each
229	registered nurse in a telemetry unit, so that the minimum
230	registered nurse-to-patient ratio is 1 to 3 or fewer at any
231	time. As used in this paragraph, the term "telemetry unit" means
232	a unit designated for the electronic monitoring, recording,
233	retrieval, and display of cardiac electrical signals.
234	(j)  No more than four patients may be assigned to each
235	registered nurse in a medical/surgical care unit, so that the
236	minimum registered nurse-to-patient ratio is 1 to 4 or fewer at
237	any time. As used in this subsection, the term "medical/surgical
238	care unit" means a unit that has beds classified as
239	medical/surgical in which patients who require less care than
240	that which is available in intensive care units or step-down
241	units receive 24-hour inpatient general medical services,
242	postsurgical services, or both general medical and postsurgical
243	services. These units may include mixed patient populations of
244	diverse diagnoses and diverse age groups.
245	(k)  No more than four patients may be assigned to each
246	registered nurse in a specialty care unit, so that the minimum
247	registered nurse-to-patient ratio is 1 to 4 or fewer at any
248	time. As used in this paragraph, the term "specialty care unit"
249	means a unit that is organized, operated, and maintained to
250	provide care for a specific medical condition or a specific
251	patient population, is more comprehensive for the specific
252	condition or disease process than the care that is available in
253	medical/surgical care units, and is not otherwise covered in
254	this section.
255	(l)  No more than four patients may be assigned to each
256	registered nurse in an acute care psychiatric unit, so that the
257	minimum registered nurse-to-patient ratio is 1 to 4 or fewer at
258	any time.
259
260	Identifying a unit by a name or term other than those used in
261	this subsection does not affect the requirement to provide staff
262	for the unit at the ratio required for the level or type of care
263	provided in the unit, as set forth in this subsection.
264	(3)  STAFFING PLAN.--Each facility licensed under this
265	chapter shall ensure that it provides sufficient, appropriately
266	qualified nursing staff of each classification in each
267	department or unit within the facility in order to meet the
268	individualized care needs of the patients. To accomplish this
269	goal, each health care facility licensed under this chapter
270	shall submit annually to the Agency for Health Care
271	Administration a documented staffing plan together with a
272	written certification that the staffing plan is sufficient to
273	provide adequate and appropriate delivery of health care
274	services to patients for the ensuing year. The staffing plan
275	must:
276	(a)  Meet the minimum requirements set forth in subsection
277	(2).
278	(b)  Be adequate to meet any additional requirements
279	provided by other laws or rules.
280	(c)  Employ and identify an approved acuity system for
281	addressing fluctuations in actual patient acuity levels and
282	nursing care requirements necessitating increased staffing
283	levels above the minimums set forth in the plan.
284	(d)  Factor in other unit or department activities, such as
285	discharges, transfers and admissions, and administrative support
286	tasks, which direct-care nurses are expected to perform in
287	addition to direct nursing care.
288	(e)  Identify the assessment tool used to validate the
289	acuity system relied on in the plan.
290	(f)  Identify the system that will be used to document
291	actual daily staffing levels within each department or unit.
292	(g)  Include a written assessment of the accuracy of the
293	previous year's staffing plan in light of actual staffing needs.
294	(h)  Identify each nurse staff classification referenced in
295	the staffing plan, together with a statement setting forth
296	minimum qualifications for each such classification.
297	(i)  Be developed in consultation with the direct-care
298	nursing staff within each department or unit or, if such staff
299	is covered by a collective bargaining agreement, with the
300	applicable recognized or certified collective bargaining
301	representatives of the direct-care nursing staff.
302	(4)  MINIMUM SKILL MIX.--The skill mix reflected in a
303	documented staffing plan must ensure that all of the following
304	elements of the nursing process are performed in the planning
305	and delivery of care for each patient: assessment, nursing
306	diagnosis, planning, intervention, evaluation, and patient
307	advocacy.
308	(a)  The skill mix may not incorporate or assume that
309	nursing care functions required by licensing law or rules or
310	accepted standards of practice to be performed by a licensed
311	nurse are to be performed by unlicensed personnel.
312	(b)  A nurse may not be assigned or included in the count
313	of assigned nursing staff for purposes of compliance with
314	minimum staffing requirements in a nursing department or unit or
315	a clinical area within the health care facility unless the nurse
316	is qualified in the area of practice to which the nurse is
317	assigned.
318	(5)  COMPLIANCE WITH PLAN.--As a condition of licensing, a
319	health care facility must at all times provide staff in
320	accordance with its documented staffing plan and the staffing
321	standards set forth in this section; however, this section does
322	not preclude a health care facility from implementing higher
323	direct-care, nurse-to-patient staffing levels.
324	(6)  RECORDKEEPING.--The facility shall maintain records
325	sufficient to allow the agency to determine the daily staffing
326	ratios and skill mixes that the facility has maintained on each
327	unit.
328	Section 5.  Section 395.055, Florida Statutes, is created
329	to read:
330	395.055  Mandatory overtime.--
331	(1)  An employee of a health care facility may not be
332	required to work overtime as defined in s. 395.053. Compelling
333	or attempting to compel an employee to work overtime is contrary
334	to public policy and is a violation of this section. The
335	acceptance by any employee of overtime work is strictly
336	voluntary, and the refusal of an employee to accept such
337	overtime work may not be grounds for discrimination, dismissal,
338	discharge, or any other penalty; threats of reports for
339	discipline; or employment decisions adverse to the employee.
340	(2)  This section does not apply to work that occurs:
341	(a)  Because of an unforeseeable emergent circumstance;
342	(b)  During prescheduled on-call time if, as of July 1,
343	2005, such prescheduled on-call time was a customary and long-
344	standing practice in the unit or department of the health care
345	facility; or
346	(c)  Because of unpredictable and unavoidable occurrences
347	relating to health care delivery which occur at unscheduled
348	intervals and require immediate action, if the employer shows
349	that the employer has exhausted reasonable efforts to comply
350	with the documented staffing plan. An employer has not made
351	reasonable efforts if overtime work is used to fill vacancies
352	resulting from chronic staff shortages.
353	(3)  This section does not prohibit a health care employee
354	from voluntarily working overtime.
355	Section 6.  Section 395.056, Florida Statutes, is created
356	to read:
357	395.056  Employee rights.--
358	(1)  A health care facility may not penalize, discriminate
359	against, or retaliate in any manner against a direct-care
360	registered nurse for refusing an assignment that would violate
361	requirements set forth in this act.
362	(2)  A health care facility may not penalize, discriminate
363	against, or retaliate in any manner against an employee with
364	respect to compensation for, or terms, conditions, or privileges
365	of, employment if such an employee in good faith, individually
366	or in conjunction with another person or persons:
367	(a)  Reports a violation or suspected violation of this act
368	to a regulatory agency, a private accreditation body, or
369	management personnel of the health care facility;
370	(b)  Initiates, cooperates in, or otherwise participates in
371	an investigation or proceeding brought by a regulatory agency or
372	private accrediting body concerning matters covered by this act;
373	(c)  Informs or discusses with any other employee, with any
374	representative of an employee, with a patient or patient
375	representative, or with the public violations or suspected
376	violations of this act; or
377	(d)  Otherwise avails himself or herself of the rights set
378	forth in this act.
379	(3)  For purposes of this section, an employee is acting in
380	good faith if the employee reasonably believes that the
381	information reported or disclosed is true and that a violation
382	has occurred or may occur.
383	Section 7.  Section 395.057, Florida Statutes, is created
384	to read:
385	395.057  Implementation and enforcement.--
386	(1)  The Agency for Health Care Administration shall
387	enforce compliance with the staffing plans and standards set
388	forth in this act. The agency may adopt rules necessary to
389	administer this act. At a minimum, the rules must provide for:
390	(a)  Unannounced, random compliance site visits to licensed
391	health care facilities subject to this act.
392	(b)  An accessible and confidential system by which the
393	public and nursing staff can report a health care facility's
394	failure to comply with this act.
395	(c)  A systematic means of investigating and correcting
396	violations of this act.
397	(d)  A graduated system of penalties, including fines,
398	withholding of reimbursement, suspension of admission to
399	specific units, and other appropriate measures, if violations
400	are not corrected.
401	(e)  Public access to information regarding reports of
402	inspections, results, deficiencies, and corrections.
403	(2)  The agency shall develop rules for administering this
404	act which require compliance with staffing standards for
405	critical care units by July 1, 2006, and compliance with all
406	provisions of this act by July 1, 2008.
407	Section 8.  This act shall take effect July 1, 2005.

CODING: Words stricken are deletions; words underlined are additions.