HB 241

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.; creating the "Safe
4	Staffing for Quality Care Act"; providing a short title;
5	providing legislative findings; defining terms;
6	prescribing safe staffing standards for health care
7	facilities; requiring licensed facilities to submit an
8	annual staffing plan to the Agency for Health Care
9	Administration; providing standards for the required skill
10	mix; requiring compliance with the staffing plan;
11	requiring recordkeeping; prohibiting mandatory overtime;
12	providing applicability; permitting employees to refuse
13	certain assignments and to report suspected violations of
14	safe staffing standards; providing for the agency to
15	enforce compliance with the act; requiring the agency to
16	develop rules; providing 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  Short title.--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 our health care delivery system are
33	resulting in a higher acuity level among patients in health care
34	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; and
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 that 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	an emergency care, ambulatory, or outpatient surgery facility
93	licensed under s. 395.003; or a psychiatric facility licensed
94	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 extra time;
119	(b)  Contacted employees who have made themselves available
120	to work extra time;
121	(c)  Sought the use of per diem staff; and
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.
147	Establishing staffing standards for registered nurses does not
148	justify providing an insufficient level of staffing by other
149	critical health care workers, including licensed practical
150	nurses, social workers, and other licensed or unlicensed
151	assistive personnel. The availability of licensed practical
152	nurses, social workers, and other licensed or unlicensed
153	assistive personnel enables registered nurses to focus on the
154	nursing care functions that only registered nurses, by law, are
155	permitted to perform and thereby helps to ensure adequate
156	staffing levels.
157	(2)  SPECIFIC STANDARDS.--Health care facilities shall
158	provide staffing by registered nurses in accordance with the
159	minimum nurse-to-patient ratios that are set forth in this
160	subsection. Staffing for care that does not require a registered
161	nurse is not included within these ratios and must be determined
162	pursuant to the patient classification system. Nurse-to-patient
163	ratios represent the maximum number of patients that are
164	assigned to one registered nurse during one shift. Only nurses
165	providing direct patient care shall be included in the ratios.
166	Nurse administrators, nurse supervisors, charge nurses, and
167	other licensed nurses that do not have a specific patient care
168	assignment may not be included in the calculation of the nurse-
169	to-patient ratio. This section does not prohibit a registered
170	nurse from providing care within the scope of his or her
171	practice to a patient assigned to another nurse.
172	(a)  No more than two patients may be assigned to each
173	registered nurse, so that the minimum registered nurse-to-
174	patient ratio in a critical care unit is 1 to 2 or fewer at any
175	time. As used in this paragraph, the term "critical care unit"
176	means a nursing unit of a general acute care hospital that
177	provides one of the following services: an intensive care
178	service, a postanesthesia recovery service, a burn center
179	service, a coronary care service, or an acute respiratory
180	service. In the intensive care newborn nursery service, no more
181	than two patients may be assigned to each nurse.
182	(b)  In the surgical service operating room, no more than
183	one patient-occupied operating room may be assigned to each
184	registered nurse.
185	(c)  No more than two patients may be assigned to each
186	registered nurse in a labor and delivery unit of the perinatal
187	service, so that the registered nurse-to-patient ratio is 1 to 2
188	or fewer at any time.
189	(d)  No more than three mother-baby couplets may be
190	assigned to each registered nurse in a postpartum area of the
191	perinatal unit at any time. If multiple births have occurred,
192	the total number of mothers plus infants which are assigned to a
193	single registered nurse may not exceed six.
194	(e)  In a hospital that provides basic emergency medical
195	services or comprehensive emergency medical services, no more
196	than three patients who are receiving emergency services may be
197	assigned to each registered nurse, so that the registered nurse-
198	to-patient ratio in an emergency department is 1 to 3 or fewer
199	at any time patients are receiving treatment. No fewer than two
200	registered nurses must be physically present in the emergency
201	department when a patient is present.
202	(f)  The nurse assigned to triage patients may not have a
203	patient assignment, may not be assigned the responsibility for
204	the base ratio, and may not be counted in the registered nurse-
205	to-patient ratio.
206	(g)  When nursing staff are attending critical care
207	patients in the emergency department, no more than two patients
208	may be assigned to each registered nurse. When nursing staff in
209	the emergency department are attending trauma patients, no more
210	than one patient may be assigned to each registered nurse at any
211	time.
212	(h)  No more than three patients may be assigned to each
213	registered nurse in a step-down unit, so that the minimum
214	registered nurse-to-patient ratio in a step-down unit is 1 to 3
215	or fewer at any time. As used in this paragraph, the term:
216	1.  "Artificial life support" means a system that uses
217	medical technology to aid, support, or replace a vital function
218	of the body which has been seriously damaged.
219	2.  "Step-down unit" means a unit that is organized,
220	operated, and maintained to provide for the monitoring and care
221	of patients who have moderate or potentially severe physiologic
222	instability that requires technical support but not necessarily
223	artificial life support.
224	3.  "Technical support" means specialized equipment or
225	personnel, or both, that provide for invasive monitoring,
226	telemetry, and mechanical ventilation, for the immediate
227	amelioration or remediation of severe pathology for those
228	patients who require less care than intensive care but more care
229	than can be provided in a medical surgical unit.
230	(i)  No more than three patients may be assigned to each
231	registered nurse, so that the minimum registered nurse-to-
232	patient ratio in a telemetry unit is 1 to 3 or fewer at any
233	time. As used in this paragraph, the term "telemetry unit" means
234	a unit designated for the electronic monitoring, recording,
235	retrieval, and display of cardiac electrical signals.
236	(j)  No more than four patients may be assigned to each
237	registered nurse, so that the minimum registered nurse-to-
238	patient ratio in medical surgical care units is 1 to 4 or fewer
239	at any time. As used in this paragraph, the term "medical
240	surgical unit" means a unit that has beds classified as medical
241	surgical in which patients who require less care than can be
242	provided in intensive care units or step-down units receive 24-
243	hour inpatient general medical services, postsurgical services,
244	or both general medical and postsurgical services. These units
245	may include mixed patient populations of diverse diagnoses and
246	diverse age groups.
247	(k)  No more than four patients may be assigned to each
248	registered nurse, so that the minimum registered nurse-to-
249	patient ratio in a specialty care unit is 1 to 4 or fewer at any
250	time. As used in this paragraph, the term "specialty care unit"
251	means a unit that is organized, operated, and maintained to
252	provide care for a specific medical condition or a specific
253	patient population, is more comprehensive for the specific
254	condition or disease process than can be provided in a medical
255	surgical unit, and is not otherwise covered in this section.
256	(l)  No more than four patients may be assigned to each
257	registered nurse, so that the minimum registered nurse-to-
258	patient ratio in an acute care psychiatric unit is 1 to 4 or
259	fewer at any time.
260
261	Identifying a unit by a name or term other than those used in
262	this subsection does not affect the requirement to provide staff
263	for the unit at the ratio required for the level or type of care
264	provided in the unit, as set forth in this subsection.
265	(3)  STAFFING PLAN.--Each facility licensed under this
266	chapter shall ensure that it provides sufficient, appropriately
267	qualified nursing staff of each classification in each
268	department or unit within the facility in order to meet the
269	individualized care needs of the patients. To accomplish this
270	goal, each health care facility licensed under this chapter
271	shall submit annually to the agency a documented staffing plan
272	together with a written certification that the staffing plan is
273	sufficient to provide adequate and appropriate delivery of
274	health care services to patients for the ensuing year. The
275	staffing plan must:
276	(a)  Meet the minimum requirements set forth in subsection
277	(2);
278	(b)  Meet any additional requirements provided by other
279	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 that require increased staffing levels
283	above the minimums set forth in the plan;
284	(d)  Factor in other unit or department activity, such as
285	discharges, transfers, and admissions and administrative support
286	tasks that direct care nurses are expected to perform in
287	addition to providing direct nursing care;
288	(e)  Identify the assessment tool used to validate the
289	acuity system used 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 based on actual staffing needs;
294	(h)  Identify each nurse staff classification referred to
295	in the staffing plan, together with a statement setting forth
296	minimum qualifications for each classification; and
297	(i)  Be developed in consultation with the direct care
298	nursing staff in each department or unit or, if such staff is
299	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 that are required by licensing law or
310	rules or accepted standards of practice to be performed by a
311	licensed nurse are to be performed by unlicensed assistant
312	personnel.
313	(b)  A nurse may not be assigned to or included in the
314	count of assigned nursing staff for purposes of compliance with
315	minimum staffing requirements in a nursing department or unit or
316	a clinical area within the health care facility unless the nurse
317	is qualified in the area of practice to which the nurse is
318	assigned.
319	(5)  COMPLIANCE WITH PLAN.--As a condition of licensing, a
320	health care facility must at all times provide staff in
321	accordance with its documented staffing plan and the staffing
322	standards set forth in this section; however, this section does
323	not preclude a health care facility from implementing higher
324	direct care, nurse-to-patient staffing levels.
325	(6)  RECORDKEEPING.--The facility shall maintain records
326	sufficient to allow the agency to determine the daily staffing
327	ratios and skill mixes that the facility has maintained on each
328	unit.
329	Section 5.  Section 395.055, Florida Statutes, is created
330	to read:
331	395.055  Mandatory overtime.--
332	(1)  An employee of a health care facility may not be
333	required to work overtime as defined in s. 395.053. Compelling
334	or attempting to compel an employee to work overtime is contrary
335	to public policy and is a violation of this section. The
336	acceptance by any employee of overtime work is strictly
337	voluntary, and the refusal of an employee to accept such
338	overtime work may not be grounds for discrimination, dismissal,
339	discharge, or any other penalty; threats of reports for
340	discipline; or employment decisions adverse to the employee.
341	(2)  This section does not apply to work that occurs:
342	(a)  Because of an unforeseeable emergent circumstance;
343	(b)  During prescheduled on-call time if, as of July 1,
344	2009, such prescheduled on-call time was a customary and
345	longstanding practice in the unit or department of the health
346	care facility; or
347	(c)  Because of unpredictable and unavoidable occurrences
348	relating to health care delivery that occur at unscheduled
349	intervals and require immediate action, if the employer shows
350	that the employer has exhausted reasonable efforts to comply
351	with the documented staffing plan. An employer has not used
352	reasonable efforts if overtime work is used to fill vacancies
353	resulting from chronic staff shortages.
354	(3)  This section does not prohibit a health care employee
355	from voluntarily working overtime.
356	Section 6.  Section 395.056, Florida Statutes, is created
357	to read:
358	395.056  Employee rights.--
359	(1)  A health care facility may not penalize, discriminate
360	against, or retaliate in any manner against a direct care
361	registered nurse for refusing an assignment that would violate
362	requirements of this act.
363	(2)  A health care facility may not penalize, discriminate
364	against, or retaliate in any manner against an employee with
365	respect to compensation for, or terms, conditions, or privileges
366	of, employment if such an employee in good faith, individually
367	or in conjunction with another person or persons:
368	(a)  Reports a violation or suspected violation of this act
369	to a regulatory agency, a private accreditation body, or
370	management personnel of the health care facility;
371	(b)  Initiates, cooperates in, or otherwise participates in
372	an investigation or proceeding brought by a regulatory agency or
373	private accreditation body concerning matters covered by this
374	act;
375	(c)  Informs or discusses with any other employee, any
376	representative of the employee, a patient or a patient's
377	representative, or with the public violations or suspected
378	violations of this act; or
379	(d)  Otherwise avails himself or herself of the rights set
380	forth in this act.
381	(3)  For purposes of this section, an employee is acting in
382	good faith if the employee reasonably believes that the
383	information reported or disclosed is true and that a violation
384	has occurred or may occur.
385	Section 7.  Section 395.057, Florida Statutes, is created
386	to read:
387	395.057  Implementation and enforcement.--
388	(1)  The agency shall enforce compliance with the staffing
389	plans and standards set forth in this act. The agency may adopt
390	rules necessary to administer this act. At a minimum, the rules
391	must provide for:
392	(a)  Unannounced, random compliance site visits to licensed
393	health care facilities subject to this act;
394	(b)  An accessible and confidential system by which the
395	public and nursing staff can report a health care facility's
396	failure to comply with this act;
397	(c)  A systematic means of investigating and correcting
398	violations of this act;
399	(d)  A graduated system of penalties, including fines,
400	withholding of reimbursement, suspension of admission to
401	specific units, and other appropriate measures, if violations
402	are not corrected; and
403	(e)  Public access to information regarding reports of
404	inspections, results, deficiencies, and corrections.
405	(2)  The agency shall develop rules for administering this
406	act which require compliance with staffing standards for
407	critical care units by July 1, 2010, and compliance with all
408	provisions of this act by July 1, 2012.
409	Section 8.  This act shall take effect July 1, 2009.

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