Senate Bill sb1176

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    Florida Senate - 2005                                  SB 1176

    By Senator Campbell





    32-959-05

  1                      A bill to be entitled

  2         An act relating to the staffing of health care

  3         facilities; creating ss. 395.051-395.057, F.S.;

  4         providing a short title; providing legislative

  5         findings; defining terms; prescribing safe

  6         staffing standards for health care facilities;

  7         requiring licensed facilities to submit an

  8         annual staffing plan to the Agency for Health

  9         Care Administration; providing standards for

10         the required skill mix; requiring compliance

11         with the staffing plan; requiring

12         recordkeeping; prohibiting mandatory overtime;

13         providing applicability; providing to employees

14         the right to refuse certain assignments and the

15         right to report suspected violations of safe

16         staffing standards; providing for the agency to

17         enforce compliance with the act; requiring the

18         agency to develop rules; providing an effective

19         date.

20  

21  Be It Enacted by the Legislature of the State of Florida:

22  

23         Section 1.  Section 395.051, Florida Statutes, is

24  created to read:

25         395.051  Short title.--Sections 395.051-395.057 may be

26  cited as the "Safe Staffing for Quality Care Act."

27         Section 2.  Section 395.052, Florida Statutes, is

28  created to read:

29         395.052  Legislative findings.--The Legislature finds

30  that:

31  

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 1         (1)  The state has a substantial interest in assuring

 2  that delivery of health care services to patients in health

 3  care facilities located in this state is adequate and safe and

 4  that health care facilities retain sufficient nursing staff so

 5  as to promote optimal health care outcomes.

 6         (2)  Recent changes in our health care delivery system

 7  are resulting in a higher acuity level among patients in

 8  health care facilities.

 9         (3)  Registered nurses constitute the highest

10  percentage of direct health care staff in acute care

11  facilities and have a central role in delivering health care.

12         (4)  Extensive research indicates that inadequate

13  registered nurse staffing in hospitals can result in increased

14  patient death rates, dangerous medical errors, and increased

15  length of stay.

16         (5)  To ensure adequate protection and care for

17  patients in health care facilities, it is essential that

18  qualified registered nurses who are trained and authorized to

19  deliver nursing services be accessible and available to meet

20  the nursing needs of patients.

21         Section 3.  Section 395.053, Florida Statutes, is

22  created to read:

23         395.053  Definitions.--As used in this act, the term:

24         (1)  "Acuity system" means an established measurement

25  instrument that:

26         (a)  Predicts nursing care requirements for individual

27  patients based on the severity of patient illness, the need

28  for specialized equipment and technology, the intensity of

29  nursing interventions required, and the complexity of clinical

30  nursing judgment needed to design, implement, and evaluate the

31  patient's nursing care plan;

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 1         (b)  Details the amount of nursing care needed, both in

 2  the number of registered nurses and in the skill mix of

 3  nursing personnel required daily for each patient in a nursing

 4  department or unit; and

 5         (c)  Is stated in terms that can be readily used and

 6  understood by direct-care nursing staff.

 7         (2)  "Assessment tool" means a measurement system that

 8  compares the staffing level in each nursing department or unit

 9  against actual patient nursing care requirements in order to

10  review the accuracy of an acuity system.

11         (3)  "Declared state of emergency" means an officially

12  designated state of emergency which has been declared by a

13  federal, state, or local government official who has the

14  authority to declare that the state, county, municipality, or

15  locality is in a state of emergency. The term does not include

16  a state of emergency which results from a labor dispute in the

17  health care industry.

18         (4)  "Direct-care nurse" or "direct-care nursing staff"

19  means any registered nurse who has direct responsibility to

20  oversee or carry out medical regimens or nursing care for one

21  or more patients. A nurse administrator, nurse supervisor,

22  nurse educator, charge nurse, or other registered nurse who

23  does not have a specific patient assignment may not be

24  included in the calculation of the registered nurse-to-patient

25  ratio.

26         (5)  "Documented staffing plan" means a detailed

27  written plan that sets forth the minimum number, skill mix,

28  and classification of licensed nurses required in each nursing

29  department or unit in the health care facility for a given

30  year, based on reasonable projections derived from the patient

31  census and average acuity level within each department or unit

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 1  during the previous year, the department or unit size and

 2  geography, the nature of services provided, and any

 3  foreseeable changes in department or unit size or function

 4  during the current year.

 5         (6)  "Health care facility" means an acute care

 6  hospital; an emergency care, ambulatory, or outpatient surgery

 7  facility licensed under s. 395.003; or a psychiatric facility

 8  licensed under chapter 394.

 9         (7)  "Nurse" means a registered nurse.

10         (8)  "Nursing care" means care that falls within the

11  scope of practice set forth in chapter 464 and other laws and

12  rules or care that is otherwise encompassed within recognized

13  professional standards of nursing practice, including

14  assessment, nursing diagnosis, planning, intervention,

15  evaluation, and patient advocacy.

16         (9)  "On-call time" means time spent by an employee

17  who:

18         (a)  Is not working on the premises of the place of

19  employment but who is compensated for availability; or

20         (b)  As a condition of employment, has agreed to be

21  available to return to the premises of the place of employment

22  on short notice if the need arises.

23         (10)  "Overtime" means the hours worked in excess of

24  any of the following:

25         (a)  An agreed-upon, predetermined, regularly scheduled

26  shift;

27         (b)  Twelve hours in a 24-hour period; or

28         (c)  Eighty hours in a consecutive 14-day period.

29         (11)  "Reasonable efforts," in reference to the

30  prohibition on mandatory overtime, means that the employer is

31  unable to obtain staff coverage even though the employer has:

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 1         (a)  Sought, from among all available qualified staff

 2  who are working, individuals who would volunteer to work extra

 3  time;

 4         (b)  Contacted employees who have made themselves

 5  available to work extra time;

 6         (c)  Sought the use of per diem staff; and

 7         (d)  Sought personnel from a contracted temporary

 8  agency if such staffing is permitted by law or an applicable

 9  collective bargaining agreement.

10         (12)  "Skill mix" means the differences in licensing,

11  specialty, and experience among direct-care nurses.

12         (13)  "Staffing level" means the actual numerical

13  registered nurse-to-patient ratio within a nursing department

14  or unit.

15         (14)  "Unforeseeable emergent circumstance" means:

16         (a)  An unforeseen declared national, state, or

17  municipal emergency;

18         (b)  A situation in which a health care disaster plan

19  is activated; or

20         (c)  An unforeseen disaster or other catastrophic event

21  that substantially affects or increases the need for health

22  care services.

23         Section 4.  Section 395.054, Florida Statutes, is

24  created to read:

25         395.054  Facility staffing standards.--

26         (1)  STAFFING PRINCIPLES.--The basic principles of

27  staffing in health care facilities should be focused on

28  patient health care needs and based on consideration of

29  patient acuity levels and services that need to be provided to

30  ensure optimal outcomes. Safe staffing practices recognize the

31  importance of all health care workers in providing quality

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 1  patient care. The setting of staffing standards for registered

 2  nurses is not to be interpreted as justifying the

 3  understaffing of other critical health care workers, including

 4  licensed practical nurses, social workers, and other licensed

 5  or unlicensed assistive personnel. Indeed, the availability of

 6  these other health care workers enables registered nurses to

 7  focus on the nursing care functions that only registered

 8  nurses, by law, are permitted to perform and thereby helps to

 9  ensure adequate staffing levels.

10         (2)  SPECIFIC STANDARDS.--Health care facilities shall

11  provide staffing by registered nurses in accordance with the

12  minimum nurse-to-patient ratios that are set forth in this

13  subsection. Staffing for care that does not require a

14  registered nurse is not included within these ratios and must

15  be determined pursuant to the patient classification system.

16  Nurse-to-patient ratios represent the maximum number of

17  patients which are assigned to one registered nurse during one

18  shift. Only nurses providing direct patient care shall be

19  included in the ratios. Nurse administrators, nurse

20  supervisors, charge nurses, and other licensed nurses that do

21  not have a specific patient care assignment may not be

22  included in the calculation of the nurse-to-patient ratio.

23  This section does not prohibit a registered nurse from

24  providing care within the scope of his or her practice to a

25  patient assigned to another nurse.

26         (a)  No more than two patients may be assigned to each

27  registered nurse, so that the minimum registered

28  nurse-to-patient ratio in a critical care unit is 1:2 or fewer

29  at any time. As used in this paragraph, the term "critical

30  care unit" means a nursing unit of a general acute care

31  hospital which provides one of the following services: an

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 1  intensive care service, a post-anesthesia recovery service, a

 2  burn center service, a coronary care service, or an acute

 3  respiratory service. In the intensive care newborn nursery

 4  service, no more than two patients may be assigned to each

 5  nurse.

 6         (b)  In the surgical service operating room, no more

 7  than one patient-occupied operating room may be assigned to

 8  each registered nurse.

 9         (c)  No more than two patients may be assigned to each

10  registered nurse in a labor/delivery unit of the perinatal

11  service, so that the registered nurse-to-patient ratio is 1:2

12  or fewer at any time.

13         (d)  No more than three mother-baby couplets may be

14  assigned to each registered nurse in a postpartum area of the

15  perinatal unit at any time. If multiple births have occurred,

16  the total number of mothers plus infants which are assigned to

17  a single registered nurse may not exceed six.

18         (e)  In a hospital that provides basic emergency

19  medical services or comprehensive emergency medical services,

20  no more than three patients who are receiving emergency

21  services may be assigned to each registered nurse, so that the

22  registered nurse-to-patient ratio in an emergency department

23  is 1:3 or fewer at any time patients are receiving treatment.

24  No fewer than two registered nurses must be physically present

25  in the emergency department when a patient is present.

26         (f)  The nurse assigned to triage patients may not have

27  a patient assignment, may not be assigned the responsibility

28  for the base ratio, and may not be counted in the registered

29  nurse-to-patient ratio.

30         (g)  When nursing staff are attending critical care

31  patients in the emergency department, no more than two

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 1  patients may be assigned to each registered nurse. When

 2  nursing staff in the emergency department are attending trauma

 3  patients, no more than one patient may be assigned to each

 4  registered nurse at any time.

 5         (h)  No more than three patients may be assigned to

 6  each registered nurse in a step-down unit, so that the minimum

 7  registered nurse-to-patient ratio in a step-down unit is 1:3

 8  or fewer at any time. As used in this paragraph, the term:

 9         1.  "Artificial life support" means a system that uses

10  medical technology to aid, support, or replace a vital

11  function of the body which has been seriously damaged.

12         2.  "Step-down unit" means a unit that is organized,

13  operated, and maintained to provide for the monitoring and

14  care of patients who have moderate or potentially severe

15  physiologic instability that requires technical support but

16  not necessarily artificial life support.

17         3.  "Technical support" means specialized equipment or

18  personnel, or both, that provides for invasive monitoring,

19  telemetry, and mechanical ventilation, for the immediate

20  amelioration or remediation of severe pathology for those

21  patients who require less care than intensive care but more

22  than that which is available from medical/surgical care.

23         (i)  No more than three patients may be assigned to

24  each registered nurse, so that the minimum registered

25  nurse-to-patient ratio in a telemetry unit is 1:3 or fewer at

26  any time. As used in this paragraph, the term "telemetry unit"

27  means a unit designated for the electronic monitoring,

28  recording, retrieval, and display of cardiac electrical

29  signals.

30         (j)  No more than four patients may be assigned to each

31  registered nurse, so that the minimum registered

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 1  nurse-to-patient ratio in medical/surgical care units is 1:4

 2  or fewer at any time. As used in this paragraph, the term

 3  "medical/surgical unit" means a unit that has beds classified

 4  as medical/surgical in which patients who require less care

 5  than that which is available in intensive care units or

 6  step-down units receive 24-hour inpatient general medical

 7  services, post-surgical services, or both general medical and

 8  post-surgical services. These units may include mixed patient

 9  populations of diverse diagnoses and diverse age groups.

10         (k)  No more than four patients may be assigned to each

11  registered nurse, so that the minimum registered

12  nurse-to-patient ratio in a specialty care unit is 1:4 or

13  fewer at any time. As used in this paragraph, the term

14  "specialty care unit" means a unit that is organized,

15  operated, and maintained to provide care for a specific

16  medical condition or a specific patient population, is more

17  comprehensive for the specific condition or disease process

18  than the care that is available on medical/surgical units, and

19  is not otherwise covered in this section.

20         (l)  No more than four patients may be assigned to each

21  registered nurse, so that the minimum registered

22  nurse-to-patient ratio in an acute care psychiatric unit is

23  1:4 or fewer at any time.

24  

25  Identifying a unit by a name or term other than those used in

26  this subsection does not affect the requirement to provide

27  staff for the unit at the ratio required for the level or type

28  of care provided in the unit, as set forth in this subsection.

29         (3)  STAFFING PLAN.--Each facility licensed under this

30  chapter shall ensure that it provides sufficient,

31  appropriately qualified nursing staff of each classification

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 1  in each department or unit within the facility in order to

 2  meet the individualized care needs of the patients. To

 3  accomplish this goal, each health care facility licensed under

 4  this chapter shall submit annually to the Agency for Health

 5  Care Administration a documented staffing plan together with a

 6  written certification that the staffing plan is sufficient to

 7  provide adequate and appropriate delivery of health care

 8  services to patients for the ensuing year. The staffing plan

 9  must:

10         (a)  Meet the minimum requirements set forth in

11  subsection (2);

12         (b)  Be adequate to meet any additional requirements

13  provided by other laws or rules;

14         (c)  Employ and identify an approved acuity system for

15  addressing fluctuations in actual patient acuity levels and

16  nursing care requirements requiring increased staffing levels

17  above the minimums set forth in the plan;

18         (d)  Factor in other unit or department activity, such

19  as discharges, transfers and admissions, and administrative

20  support tasks, which direct-care nurses are expected to do in

21  addition to performing direct nursing care;

22         (e)  Identify the assessment tool used to validate the

23  acuity system relied on in the plan;

24         (f)  Identify the system that will be used to document

25  actual daily staffing levels within each department or unit;

26         (g)  Include a written assessment of the accuracy of

27  the previous year's staffing plan in light of actual staffing

28  needs;

29         (h)  Identify each nurse staff classification

30  referenced in the staffing plan, together with a statement

31  

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 1  setting forth minimum qualifications for each such

 2  classification; and

 3         (i)  Be developed in consultation with the direct-care

 4  nursing staff within each department or unit or, if such staff

 5  is covered by a collective bargaining agreement, with the

 6  applicable recognized or certified collective bargaining

 7  representatives of the direct-care nursing staff.

 8         (4)  MINIMUM SKILL MIX.--The skill mix reflected in a

 9  documented staffing plan must assure that all of the following

10  elements of the nursing process are performed in the planning

11  and delivery of care for each patient: assessment, nursing

12  diagnosis, planning, intervention, evaluation, and patient

13  advocacy.

14         (a)  The skill mix may not incorporate or assume that

15  nursing care functions required by licensing law or rules or

16  accepted standards of practice to be performed by a licensed

17  nurse are to be performed by unlicensed assistant personnel.

18         (b)  A nurse may not be assigned or included in the

19  count of assigned nursing staff for purposes of compliance

20  with minimum staffing requirements in a nursing department or

21  unit or a clinical area within the health care facility unless

22  the nurse is qualified in the area of practice to which the

23  nurse is assigned.

24         (5)  COMPLIANCE WITH PLAN.--As a condition of

25  licensing, a health care facility must at all times provide

26  staff in accordance with its documented staffing plan and the

27  staffing standards set forth in this section; however, this

28  section does not preclude a health care facility from

29  implementing higher direct-care, nurse-to-patient staffing

30  levels.

31  

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 1         (6)  RECORDKEEPING.--The facility shall maintain

 2  records sufficient to allow the agency to determine the daily

 3  staffing ratios and skill mixes that the facility has

 4  maintained on each unit.

 5         Section 5.  Section 395.055, Florida Statutes, is

 6  created to read:

 7         395.055  Mandatory overtime.--

 8         (1)  An employee of a health care facility may not be

 9  required to work overtime as defined in s. 395.053. Compelling

10  or attempting to compel an employee to work overtime is

11  contrary to public policy and is a violation of this section.

12  The acceptance by any employee of overtime work is strictly

13  voluntary, and the refusal of an employee to accept such

14  overtime work may not be grounds for discrimination,

15  dismissal, discharge, or any other penalty; threats of reports

16  for discipline; or employment decisions adverse to the

17  employee.

18         (2)  This section does not apply to work that occurs:

19         (a)  Because of an unforeseeable emergent circumstance;

20         (b)  During prescheduled on-call time if, as of July 1,

21  2005, such prescheduled on-call time was a customary and

22  longstanding practice in the unit or department of the health

23  care facility; or

24         (c)  Because of unpredictable and unavoidable

25  occurrences relating to health care delivery which occur at

26  unscheduled intervals and require immediate action, if the

27  employer shows that the employer has exhausted reasonable

28  efforts to comply with the documented staffing plan. An

29  employer has not used reasonable efforts if overtime work is

30  used to fill vacancies resulting from chronic staff shortages.

31  

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 1         (3)  This section does not prohibit a health care

 2  employee from voluntarily working overtime.

 3         Section 6.  Section 395.056, Florida Statutes, is

 4  created to read:

 5         395.056  Employee rights.--

 6         (1)  A health care facility may not penalize,

 7  discriminate against, or retaliate in any manner against a

 8  direct-care registered nurse for refusing an assignment that

 9  would violate requirements set forth in this act.

10         (2)  A health care facility may not penalize,

11  discriminate against, or retaliate in any manner against an

12  employee with respect to compensation for, or terms,

13  conditions, or privileges of, employment if such an employee

14  in good faith, individually or in conjunction with another

15  person or persons:

16         (a)  Reports a violation or suspected violation of this

17  act to a regulatory agency, a private accreditation body, or

18  management personnel of the health care facility;

19         (b)  Initiates, cooperates in, or otherwise

20  participates in an investigation or proceeding brought by a

21  regulatory agency or private accreditation body concerning

22  matters covered by this act;

23         (c)  Informs or discusses with any other employee, with

24  any representative of the employees, with a patient or patient

25  representative, or with the public violations or suspected

26  violations of this act; or

27         (d)  Otherwise avails himself or herself of the rights

28  set forth in this act.

29         (3)  For purposes of this section, an employee is

30  acting in good faith if the employee reasonably believes that

31  

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 1  the information reported or disclosed is true and that a

 2  violation has occurred or may occur.

 3         Section 7.  Section 395.057, Florida Statutes, is

 4  created to read:

 5         395.057  Implementation and enforcement.--

 6         (1)  The Agency for Health Care Administration shall

 7  enforce compliance with the staffing plans and standards set

 8  forth in this act. The agency may adopt rules necessary to

 9  administer this act. At a minimum, the rules must provide for:

10         (a)  Unannounced, random compliance site visits to

11  licensed health care facilities subject to this act;

12         (b)  An accessible and confidential system by which the

13  public and nursing staff can report a health care facility's

14  failure to comply with this act;

15         (c)  A systematic means of investigating and correcting

16  violations of this act;

17         (d)  A graduated system of penalties, including fines,

18  withholding of reimbursement, suspension of admission to

19  specific units, and other appropriate measures, if violations

20  are not corrected; and

21         (e)  Public access to information regarding reports of

22  inspections, results, deficiencies, and corrections.

23         (3)  The agency shall develop rules for administering

24  this act which require compliance with staffing standards for

25  critical care units by July 1, 2006, and compliance with all

26  provisions of this act by July 1, 2008.

27         Section 8.  This act shall take effect July 1, 2005.

28  

29  

30  

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 1            *****************************************

 2                          SENATE SUMMARY

 3    Creates the "Safe Staffing for Quality Care Act."
      Provides legislative findings. Defines terms. Prescribes
 4    safe staffing standards for health care facilities.
      Requires licensed facilities to submit an annual staffing
 5    plan to the Agency for Health Care Administration.
      Provides standards for the required skill mix. Requires
 6    compliance with the staffing plan. Requires
      recordkeeping. Prohibits mandatory overtime. Provides
 7    applicability. Provides to employees the right to refuse
      certain assignments and the right to report suspected
 8    violations of safe staffing standards without incurring a
      penalty. Provides for the agency to enforce compliance
 9    with the act. Requires the agency to develop rules.

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