1

A bill to be entitled

2

An act relating to nursing facilities; amending s.

3

400.141, F.S.; authorizing certain licensed nursing

4

facilities to develop a plan to provide certain training

5

for nursing assistants; providing for rules relating to

6

agency approval of training programs; amending s. 400.147,

7

F.S.; redefining the term "adverse incident"; deleting the

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requirement that a nursing facility notify the agency of

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an adverse incident; deleting notification requirements;

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requiring that a risk manager determine if an incident was

11

an adverse incident; providing that federal reporting

12

requirements are not affected; amending s. 400.19, F.S.;

13

providing that the most recent survey is a licensure

14

survey under certain conditions for purposes of future

15

survey scheduling; amending s. 400.195, F.S., relating to

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agency reporting requirements; conforming a cross-

17

reference; amending s. 400.23, F.S.; deleting provisions

18

requiring agency approval in order for a nursing home to

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use licensed nurses to perform certain duties; providing

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an effective date.

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

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     Section 1.  Section 400.141, Florida Statutes, is amended to

25

read:

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     400.141  Administration and management of nursing home

27

facilities.--Every licensed facility shall comply with all

28

applicable standards and rules of the agency and shall:

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     (1)  Be under the administrative direction and charge of a

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licensed administrator.

31

     (2)  Appoint a medical director licensed pursuant to chapter

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458 or chapter 459. The agency may establish by rule more

33

specific criteria for the appointment of a medical director.

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     (3)  Have available the regular, consultative, and emergency

35

services of physicians licensed by the state.

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     (4)  Provide for resident use of a community pharmacy as

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specified in s. 400.022(1)(q). Any other law to the contrary

38

notwithstanding, a registered pharmacist licensed in Florida,

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that is under contract with a facility licensed under this

40

chapter or chapter 429, shall repackage a nursing facility

41

resident's bulk prescription medication which has been packaged

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by another pharmacist licensed in any state in the United States

43

into a unit dose system compatible with the system used by the

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nursing facility, if the pharmacist is requested to offer such

45

service. In order to be eligible for the repackaging, a resident

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or the resident's spouse must receive prescription medication

47

benefits provided through a former employer as part of his or her

48

retirement benefits, a qualified pension plan as specified in s.

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4972 of the Internal Revenue Code, a federal retirement program

50

as specified under 5 C.F.R. s. 831, or a long-term care policy as

51

defined in s. 627.9404(1). A pharmacist who correctly repackages

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and relabels the medication and the nursing facility which

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correctly administers such repackaged medication under the

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provisions of this subsection shall not be held liable in any

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civil or administrative action arising from the repackaging. In

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order to be eligible for the repackaging, a nursing facility

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resident for whom the medication is to be repackaged shall sign

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an informed consent form provided by the facility which includes

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an explanation of the repackaging process and which notifies the

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resident of the immunities from liability provided herein. A

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pharmacist who repackages and relabels prescription medications,

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as authorized under this subsection, may charge a reasonable fee

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for costs resulting from the implementation of this provision.

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     (5)  Provide for the access of the facility residents to

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dental and other health-related services, recreational services,

66

rehabilitative services, and social work services appropriate to

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their needs and conditions and not directly furnished by the

68

licensee.  When a geriatric outpatient nurse clinic is conducted

69

in accordance with rules adopted by the agency, outpatients

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attending such clinic shall not be counted as part of the general

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resident population of the nursing home facility, nor shall the

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nursing staff of the geriatric outpatient clinic be counted as

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part of the nursing staff of the facility, until the outpatient

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clinic load exceeds 15 a day.

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     (6)  Be allowed and encouraged by the agency to provide

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other needed services under certain conditions. If the facility

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has a standard licensure status, and has had no class I or class

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II deficiencies during the past 2 years or has been awarded a

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Gold Seal under the program established in s. 400.235, it may be

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encouraged by the agency to provide services, including, but not

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limited to, respite and adult day services, which enable

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individuals to move in and out of the facility.  A facility is

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not subject to any additional licensure requirements for

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providing these services. Respite care may be offered to persons

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in need of short-term or temporary nursing home services. Respite

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care must be provided in accordance with this part and rules

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adopted by the agency. However, the agency shall, by rule, adopt

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modified requirements for resident assessment, resident care

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plans, resident contracts, physician orders, and other

90

provisions, as appropriate, for short-term or temporary nursing

91

home services.  The agency shall allow for shared programming and

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staff in a facility which meets minimum standards and offers

93

services pursuant to this subsection, but, if the facility is

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cited for deficiencies in patient care, may require additional

95

staff and programs appropriate to the needs of service

96

recipients. A person who receives respite care may not be counted

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as a resident of the facility for purposes of the facility's

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licensed capacity unless that person receives 24-hour respite

99

care. A person receiving either respite care for 24 hours or

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longer or adult day services must be included when calculating

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minimum staffing for the facility. Any costs and revenues

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generated by a nursing home facility from nonresidential programs

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or services shall be excluded from the calculations of Medicaid

104

per diems for nursing home institutional care reimbursement.

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     (7)  If the facility has a standard license or is a Gold

106

Seal facility, exceeds the minimum required hours of licensed

107

nursing and certified nursing assistant direct care per resident

108

per day, and is part of a continuing care facility licensed under

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chapter 651 or a retirement community that offers other services

110

pursuant to part III of this chapter or part I or part III of

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chapter 429 on a single campus, be allowed to share programming

112

and staff. At the time of inspection and in the semiannual report

113

required pursuant to subsection (15), a continuing care facility

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or retirement community that uses this option must demonstrate

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through staffing records that minimum staffing requirements for

116

the facility were met. Licensed nurses and certified nursing

117

assistants who work in the nursing home facility may be used to

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provide services elsewhere on campus if the facility exceeds the

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minimum number of direct care hours required per resident per day

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and the total number of residents receiving direct care services

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from a licensed nurse or a certified nursing assistant does not

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cause the facility to violate the staffing ratios required under

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s. 400.23(3)(a). Compliance with the minimum staffing ratios

124

shall be based on total number of residents receiving direct care

125

services, regardless of where they reside on campus. If the

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facility receives a conditional license, it may not share staff

127

until the conditional license status ends. This subsection does

128

not restrict the agency's authority under federal or state law to

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require additional staff if a facility is cited for deficiencies

130

in care which are caused by an insufficient number of certified

131

nursing assistants or licensed nurses. The agency may adopt rules

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for the documentation necessary to determine compliance with this

133

provision.

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     (8)  Maintain the facility premises and equipment and

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conduct its operations in a safe and sanitary manner.

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     (9)  If the licensee furnishes food service, provide a

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wholesome and nourishing diet sufficient to meet generally

138

accepted standards of proper nutrition for its residents and

139

provide such therapeutic diets as may be prescribed by attending

140

physicians.  In making rules to implement this subsection, the

141

agency shall be guided by standards recommended by nationally

142

recognized professional groups and associations with knowledge of

143

dietetics.

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     (10)  Keep full records of resident admissions and

145

discharges; medical and general health status, including medical

146

records, personal and social history, and identity and address of

147

next of kin or other persons who may have responsibility for the

148

affairs of the residents; and individual resident care plans

149

including, but not limited to, prescribed services, service

150

frequency and duration, and service goals.  The records shall be

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open to inspection by the agency.

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     (11)  Keep such fiscal records of its operations and

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conditions as may be necessary to provide information pursuant to

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this part.

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     (12)  Furnish copies of personnel records for employees

156

affiliated with such facility, to any other facility licensed by

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this state requesting this information pursuant to this part.  

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Such information contained in the records may include, but is not

159

limited to, disciplinary matters and any reason for termination.

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Any facility releasing such records pursuant to this part shall

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be considered to be acting in good faith and may not be held

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liable for information contained in such records, absent a

163

showing that the facility maliciously falsified such records.

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     (13)  Publicly display a poster provided by the agency

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containing the names, addresses, and telephone numbers for the

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state's abuse hotline, the State Long-Term Care Ombudsman, the

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Agency for Health Care Administration consumer hotline, the

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Advocacy Center for Persons with Disabilities, the Florida

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Statewide Advocacy Council, and the Medicaid Fraud Control Unit,

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with a clear description of the assistance to be expected from

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each.

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     (14)  Submit to the agency the information specified in s.

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400.071(1)(b) for a management company within 30 days after the

174

effective date of the management agreement.

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     (15)  Submit semiannually to the agency, or more frequently

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if requested by the agency, information regarding facility staff-

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to-resident ratios, staff turnover, and staff stability,

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including information regarding certified nursing assistants,

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licensed nurses, the director of nursing, and the facility

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administrator. For purposes of this reporting:

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     (a)  Staff-to-resident ratios must be reported in the

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categories specified in s. 400.23(3)(a) and applicable rules. The

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ratio must be reported as an average for the most recent calendar

184

quarter.

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     (b)  Staff turnover must be reported for the most recent 12-

186

month period ending on the last workday of the most recent

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calendar quarter prior to the date the information is submitted.

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The turnover rate must be computed quarterly, with the annual

189

rate being the cumulative sum of the quarterly rates. The

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turnover rate is the total number of terminations or separations

191

experienced during the quarter, excluding any employee terminated

192

during a probationary period of 3 months or less, divided by the

193

total number of staff employed at the end of the period for which

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the rate is computed, and expressed as a percentage.

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     (c)  The formula for determining staff stability is the

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total number of employees that have been employed for more than

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12 months, divided by the total number of employees employed at

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the end of the most recent calendar quarter, and expressed as a

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percentage.

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     (d)  A nursing facility that has failed to comply with state

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minimum-staffing requirements for 2 consecutive days is

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prohibited from accepting new admissions until the facility has

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achieved the minimum-staffing requirements for a period of 6

204

consecutive days. For the purposes of this paragraph, any person

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who was a resident of the facility and was absent from the

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facility for the purpose of receiving medical care at a separate

207

location or was on a leave of absence is not considered a new

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admission. Failure to impose such an admissions moratorium

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constitutes a class II deficiency.

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     (e)  A nursing facility which does not have a conditional

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license may be cited for failure to comply with the standards in

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s. 400.23(3)(a)1.a. only if it has failed to meet those standards

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on 2 consecutive days or if it has failed to meet at least 97

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percent of those standards on any one day.

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     (f)  A facility which has a conditional license must be in

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compliance with the standards in s. 400.23(3)(a) at all times.

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Nothing in this section shall limit the agency's ability to

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impose a deficiency or take other actions if a facility does not

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have enough staff to meet the residents' needs.

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     (16)  Report monthly the number of vacant beds in the

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facility which are available for resident occupancy on the day

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the information is reported.

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     (17)  Notify a licensed physician when a resident exhibits

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signs of dementia or cognitive impairment or has a change of

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condition in order to rule out the presence of an underlying

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physiological condition that may be contributing to such dementia

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or impairment. The notification must occur within 30 days after

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the acknowledgment of such signs by facility staff. If an

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underlying condition is determined to exist, the facility shall

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arrange, with the appropriate health care provider, the necessary

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care and services to treat the condition.

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     (18)  If the facility implements a dining and hospitality

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attendant program, ensure that the program is developed and

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implemented under the supervision of the facility director of

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nursing. A licensed nurse, licensed speech or occupational

237

therapist, or a registered dietitian must conduct training of

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dining and hospitality attendants. A person employed by a

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facility as a dining and hospitality attendant must perform tasks

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under the direct supervision of a licensed nurse.

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     (19)  Report to the agency any filing for bankruptcy

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protection by the facility or its parent corporation, divestiture

243

or spin-off of its assets, or corporate reorganization within 30

244

days after the completion of such activity.

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     (20)  Maintain general and professional liability insurance

246

coverage that is in force at all times. In lieu of general and

247

professional liability insurance coverage, a state-designated

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teaching nursing home and its affiliated assisted living

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facilities created under s. 430.80 may demonstrate proof of

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financial responsibility as provided in s. 430.80(3)(h).

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     (21)  Maintain in the medical record for each resident a

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daily chart of certified nursing assistant services provided to

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the resident. The certified nursing assistant who is caring for

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the resident must complete this record by the end of his or her

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shift. This record must indicate assistance with activities of

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daily living, assistance with eating, and assistance with

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drinking, and must record each offering of nutrition and

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hydration for those residents whose plan of care or assessment

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indicates a risk for malnutrition or dehydration.

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     (22)  Before November 30 of each year, subject to the

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availability of an adequate supply of the necessary vaccine,

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provide for immunizations against influenza viruses to all its

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consenting residents in accordance with the recommendations of

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the United States Centers for Disease Control and Prevention,

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subject to exemptions for medical contraindications and religious

266

or personal beliefs. Subject to these exemptions, any consenting

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person who becomes a resident of the facility after November 30

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but before March 31 of the following year must be immunized

269

within 5 working days after becoming a resident. Immunization

270

shall not be provided to any resident who provides documentation

271

that he or she has been immunized as required by this subsection.

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This subsection does not prohibit a resident from receiving the

273

immunization from his or her personal physician if he or she so

274

chooses. A resident who chooses to receive the immunization from

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his or her personal physician shall provide proof of immunization

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to the facility. The agency may adopt and enforce any rules

277

necessary to comply with or implement this subsection.

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     (23)  Assess all residents for eligibility for pneumococcal

279

polysaccharide vaccination (PPV) and vaccinate residents when

280

indicated within 60 days after the effective date of this act in

281

accordance with the recommendations of the United States Centers

282

for Disease Control and Prevention, subject to exemptions for

283

medical contraindications and religious or personal beliefs.

284

Residents admitted after the effective date of this act shall be

285

assessed within 5 working days of admission and, when indicated,

286

vaccinated within 60 days in accordance with the recommendations

287

of the United States Centers for Disease Control and Prevention,

288

subject to exemptions for medical contraindications and religious

289

or personal beliefs. Immunization shall not be provided to any

290

resident who provides documentation that he or she has been

291

immunized as required by this subsection. This subsection does

292

not prohibit a resident from receiving the immunization from his

293

or her personal physician if he or she so chooses. A resident who

294

chooses to receive the immunization from his or her personal

295

physician shall provide proof of immunization to the facility.

296

The agency may adopt and enforce any rules necessary to comply

297

with or implement this subsection.

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     (24)  Annually encourage and promote to its employees the

299

benefits associated with immunizations against influenza viruses

300

in accordance with the recommendations of the United States

301

Centers for Disease Control and Prevention. The agency may adopt

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and enforce any rules necessary to comply with or implement this

303

subsection.

304

305

Facilities having a standard license that have been awarded a

306

Gold Seal under the program established in s. 400.235 may develop

307

a plan to provide certified nursing assistant training as

308

prescribed by federal regulations and state rules and may apply

309

to the agency for approval of their program. The agency may adopt

310

rules relating to the approval, suspension, or termination of a

311

certified nursing assistant training program.

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     Section 2.  Subsections (5) through (15) of section 400.147,

313

Florida Statutes, are amended to read:

314

     400.147  Internal risk management and quality assurance

315

program.--

316

     (5)  For purposes of reporting to the agency under this

317

section, the term "adverse incident" means:

318

     (a)  An event over which facility personnel could exercise

319

control and which is associated in whole or in part with the

320

facility's intervention, rather than the condition for which such

321

intervention occurred, and which results in one of the following:

322

     1.  Death;

323

     2.  Brain or spinal damage;

324

     3.  Permanent disfigurement;

325

     4.  Fracture or dislocation of bones or joints;

326

     5.  A limitation of neurological, physical, or sensory

327

function;

328

     6.  Any condition that required medical attention to which

329

the resident has not given his or her informed consent, including

330

failure to honor advanced directives; or

331

     7.  Any condition that required the transfer of the

332

resident, within or outside the facility, to a unit providing a

333

more acute level of care due to the adverse incident, rather than

334

the resident's condition prior to the adverse incident;

335

     (b)  Abuse, neglect, or exploitation as defined in s.

336

415.102;

337

     (c)  Abuse, neglect and harm as defined in s. 39.01;

338

     (d)  Resident elopement; or

339

     (e) An event that is reported to a law enforcement agency

340

for investigation.

341

     (6)  The internal risk manager of each licensed facility

342

shall:

343

     (a)  Investigate every allegation of sexual misconduct which

344

is made against a member of the facility's personnel who has

345

direct patient contact when the allegation is that the sexual

346

misconduct occurred at the facility or at the grounds of the

347

facility;

348

     (b)  Report every allegation of sexual misconduct to the

349

administrator of the licensed facility; and

350

     (c)  Notify the resident representative or guardian of the

351

victim that an allegation of sexual misconduct has been made and

352

that an investigation is being conducted.

353

     (7)(a) The facility shall initiate an investigation and

354

shall notify the agency within 1 business day after the risk

355

manager or his or her designee has received a report pursuant to

356

paragraph (1)(d). The notification must be made in writing and be

357

provided electronically, by facsimile device or overnight mail

358

delivery. The notification must include information regarding the

359

identity of the affected resident, the type of adverse incident,

360

the initiation of an investigation by the facility, and whether

361

the events causing or resulting in the adverse incident represent

362

a potential risk to any other resident. The notification is

363

confidential as provided by law and is not discoverable or

364

admissible in any civil or administrative action, except in

365

disciplinary proceedings by the agency or the appropriate

366

regulatory board. The agency may investigate, as it deems

367

appropriate, any such incident and prescribe measures that must

368

or may be taken in response to the incident. The agency shall

369

review each incident and determine whether it potentially

370

involved conduct by the health care professional who is subject

371

to disciplinary action, in which case the provisions of s.

372

456.073 shall apply.

373

     (b)(8)(a) Each facility shall complete the investigation

374

and submit an adverse incident report to the agency for each

375

adverse incident within 15 calendar days after its occurrence.

376

If, after a complete investigation, the risk manager determines

377

that the incident was not an adverse incident as defined in

378

subsection (5), the facility shall include this information in

379

the report. The agency shall develop a form for reporting this

380

information.

381

     (c)(b) The information reported to the agency pursuant to

382

paragraph (b) (a) which relates to persons licensed under chapter

383

458, chapter 459, chapter 461, or chapter 466 shall be reviewed

384

by the agency. The agency shall determine whether any of the

385

incidents potentially involved conduct by a health care

386

professional who is subject to disciplinary action, in which case

387

the provisions of s. 456.073 shall apply.

388

     (d)(c) The report submitted to the agency must also contain

389

the name of the risk manager of the facility.

390

     (e)(d) The adverse incident report is confidential as

391

provided by law and is not discoverable or admissible in any

392

civil or administrative action, except in disciplinary

393

proceedings by the agency or the appropriate regulatory board.

394

     (f) Federal reporting requirements are not affected by

395

provisions in this subsection.

396

     (8)(9) By the 10th of each month, each facility subject to

397

this section shall report any notice received pursuant to s.

398

400.0233(2) and each initial complaint that was filed with the

399

clerk of the court and served on the facility during the previous

400

month by a resident or a resident's family member, guardian,

401

conservator, or personal legal representative. The report must

402

include the name of the resident, the resident's date of birth

403

and social security number, the Medicaid identification number

404

for Medicaid-eligible persons, the date or dates of the incident

405

leading to the claim or dates of residency, if applicable, and

406

the type of injury or violation of rights alleged to have

407

occurred.  Each facility shall also submit a copy of the notices

408

received pursuant to s. 400.0233(2) and complaints filed with the

409

clerk of the court. This report is confidential as provided by

410

law and is not discoverable or admissible in any civil or

411

administrative action, except in such actions brought by the

412

agency to enforce the provisions of this part.

413

     (9)(10) The agency shall review, as part of its licensure

414

inspection process, the internal risk management and quality

415

assurance program at each facility regulated by this section to

416

determine whether the program meets standards established in

417

statutory laws and rules, is being conducted in a manner designed

418

to reduce adverse incidents, and is appropriately reporting

419

incidents as required by this section.

420

     (10)(11) There is no monetary liability on the part of, and

421

a cause of action for damages may not arise against, any risk

422

manager for the implementation and oversight of the internal risk

423

management and quality assurance program in a facility licensed

424

under this part as required by this section, or for any act or

425

proceeding undertaken or performed within the scope of the

426

functions of such internal risk management and quality assurance

427

program if the risk manager acts without intentional fraud.

428

     (11)(12) If the agency, through its receipt of the adverse

429

incident reports prescribed in subsection (7), or through any

430

investigation, has a reasonable belief that conduct by a staff

431

member or employee of a facility is grounds for disciplinary

432

action by the appropriate regulatory board, the agency shall

433

report this fact to the regulatory board.

434

     (12)(13) The agency may adopt rules to administer this

435

section.

436

     (13)(14) The agency shall annually submit to the

437

Legislature a report on nursing home adverse incidents. The

438

report must include the following information arranged by county:

439

     (a)  The total number of adverse incidents.

440

     (b)  A listing, by category, of the types of adverse

441

incidents, the number of incidents occurring within each

442

category, and the type of staff involved.

443

     (c)  A listing, by category, of the types of injury caused

444

and the number of injuries occurring within each category.

445

     (d)  Types of liability claims filed based on an adverse

446

incident or reportable injury.

447

     (e)  Disciplinary action taken against staff, categorized by

448

type of staff involved.

449

     (14)(15) Information gathered by a credentialing

450

organization under a quality assurance program is not

451

discoverable from the credentialing organization. This subsection

452

does not limit discovery of, access to, or use of facility

453

records, including those records from which the credentialing

454

organization gathered its information.

455

     Section 3.  Subsection (3) of section 400.19, Florida

456

Statutes, is amended to read:

457

     400.19  Right of entry and inspection.--

458

     (3)  The agency shall every 15 months conduct at least one

459

unannounced inspection to determine compliance by the licensee

460

with statutes, and with rules adopted promulgated under the

461

provisions of those statutes, governing minimum standards of

462

construction, quality and adequacy of care, and rights of

463

residents. The survey shall be conducted every 6 months for the

464

next 2-year period if the facility has been cited for a class I

465

deficiency, has been cited for two or more class II deficiencies

466

arising from separate surveys or investigations within a 60-day

467

period, or has had three or more substantiated complaints within

468

a 6-month period, each resulting in at least one class I or class

469

II deficiency. In addition to any other fees or fines in this

470

part, the agency shall assess a fine for each facility that is

471

subject to the 6-month survey cycle. The fine for the 2-year

472

period shall be $6,000, one-half to be paid at the completion of

473

each survey. The agency may adjust this fine by the change in the

474

Consumer Price Index, based on the 12 months immediately

475

preceding the increase, to cover the cost of the additional

476

surveys. If such deficiencies are overturned as the result of

477

administrative action but additional surveys have already been

478

conducted pursuant to this section, the most recent survey shall

479

be considered a licensure survey for purposes of scheduling

480

future surveys. The agency shall verify through subsequent

481

inspection that any deficiency identified during inspection is

482

corrected. However, the agency may verify the correction of a

483

class III or class IV deficiency unrelated to resident rights or

484

resident care without reinspecting the facility if adequate

485

written documentation has been received from the facility, which

486

provides assurance that the deficiency has been corrected. The

487

giving or causing to be given of advance notice of such

488

unannounced inspections by an employee of the agency to any

489

unauthorized person shall constitute cause for suspension of not

490

fewer than 5 working days according to the provisions of chapter

491

110.

492

     Section 4.  Paragraph (d) of subsection (1) of section

493

400.195, Florida Statutes, is amended to read:

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     400.195  Agency reporting requirements.--

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     (1)  For the period beginning June 30, 2001, and ending June

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30, 2005, the Agency for Health Care Administration shall provide

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a report to the Governor, the President of the Senate, and the

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Speaker of the House of Representatives with respect to nursing

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homes.  The first report shall be submitted no later than

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December 30, 2002, and subsequent reports shall be submitted

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every 6 months thereafter.  The report shall identify facilities

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based on their ownership characteristics, size, business

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structure, for-profit or not-for-profit status, and any other

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characteristics the agency determines useful in analyzing the

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varied segments of the nursing home industry and shall report:

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     (d)  Information regarding deficiencies cited, including

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information used to develop the Nursing Home Guide WATCH LIST

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pursuant to s. 400.191, and applicable rules, a summary of data

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generated on nursing homes by Centers for Medicare and Medicaid

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Services Nursing Home Quality Information Project, and

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information collected pursuant to s. 400.147(8) s. 400.147(9),

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relating to litigation.

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     Section 5.  Paragraph (a) of subsection (3) of section

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400.23, Florida Statutes, is amended to read:

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     400.23  Rules; evaluation and deficiencies; licensure

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status.--

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     (3)(a)1.  The agency shall adopt rules providing minimum

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staffing requirements for nursing homes. These requirements shall

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include, for each nursing home facility:

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     a.  A minimum certified nursing assistant staffing of 2.6

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hours of direct care per resident per day beginning January 1,

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2003, and increasing to 2.7 hours of direct care per resident per

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day beginning January 1, 2007. Beginning January 1, 2002, a no

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facility may not shall staff below one certified nursing

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assistant per 20 residents, and must provide a minimum licensed

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nursing staffing of 1.0 hour of direct care per resident per day

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but never below one licensed nurse per 40 residents.

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     b.  Beginning January 1, 2007, a minimum weekly average

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certified nursing assistant staffing of 2.9 hours of direct care

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per resident per day. For the purpose of this sub-subparagraph, a

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week is defined as Sunday through Saturday.

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     2.  Nursing assistants employed under s. 400.211(2) may be

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included in computing the staffing ratio for certified nursing

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assistants only if their job responsibilities include only

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nursing-assistant-related duties.

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     3.  Each nursing home must document compliance with staffing

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standards as required under this paragraph and post daily the

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names of staff on duty for the benefit of facility residents and

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the public.

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     4.  The agency shall recognize the use of licensed nurses

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for compliance with minimum staffing requirements for certified

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nursing assistants, provided that the facility otherwise meets

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the minimum staffing requirements for licensed nurses and that

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the licensed nurses are performing the duties of a certified

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nursing assistant. Unless otherwise approved by the agency,

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Licensed nurses counted toward the minimum staffing requirements

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for certified nursing assistants must exclusively perform the

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duties of a certified nursing assistant for the entire shift and

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not also be counted toward the minimum staffing requirements for

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licensed nurses. If the agency approved a facility's request to

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use a licensed nurse to perform both licensed nursing and

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certified nursing assistant duties, The facility must allocate

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the amount of staff time specifically spent on certified nursing

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assistant duties for the purpose of documenting compliance with

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minimum staffing requirements for certified and licensed nursing

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staff. In no event may the hours of a licensed nurse with dual

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job responsibilities be counted twice.

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     Section 6.  This act shall take effect July 1, 2008.