Florida Senate - 2019 SB 644 By Senator Braynon 35-01613-19 2019644__ 1 A bill to be entitled 2 An act relating to delivery of nursing services; 3 creating the “Florida Hospital Patient Protection 4 Act”; creating s. 395.1014, F.S.; providing 5 legislative findings; defining terms; requiring that 6 each health care facility implement a staffing plan 7 that provides minimum direct care registered nurse 8 staffing levels; requiring a direct care registered 9 nurse to demonstrate competence and to receive 10 specified orientation before being assigned to a 11 hospital or clinical unit; prohibiting a health care 12 facility from imposing mandatory overtime and from 13 engaging in certain other actions; providing 14 requirements for the staffing plan; specifying the 15 required ratios of direct care registered nurses to 16 patients for each type of care provided; prohibiting a 17 health care facility from using an acuity adjustable 18 unit to care for a patient; prohibiting a health care 19 facility from using video cameras or monitors as 20 substitutes for the required level of care; providing 21 an exception during a declared state of emergency; 22 requiring that the chief nursing officer of a health 23 care facility, or his or her designee, develop a 24 staffing plan that meets the required direct care 25 registered nurse staffing levels; requiring that a 26 health care facility annually evaluate its actual 27 direct care registered nurse staffing levels and 28 update the staffing plan and acuity-based patient 29 classification system; requiring that certain 30 documentation be submitted to the Agency for Health 31 Care Administration and be made available for public 32 inspection; requiring that the agency approve uniform 33 standards for use by health care facilities in 34 establishing direct care registered nurse staffing 35 requirements by a specified date; providing 36 requirements for the committee members who are 37 appointed to develop the uniform standards; requiring 38 health care facilities to annually report certain 39 information to the agency and to post a notice 40 containing such information in each unit of the 41 facility; providing recordkeeping requirements; 42 prohibiting a health care facility from assigning 43 unlicensed personnel to perform functions or tasks 44 that should be performed by a licensed or registered 45 nurse; specifying those actions that constitute 46 professional practice by a direct care registered 47 nurse; requiring that a patient assessment be 48 performed only by a direct care registered nurse; 49 authorizing a direct care registered nurse to assign 50 certain specified activities to other licensed or 51 unlicensed nursing staff under certain circumstances; 52 prohibiting a health care facility from deploying 53 technology that limits certain care provided by a 54 direct care registered nurse; providing applicability; 55 providing that it is a duty and right of a direct care 56 registered nurse to act as the patient’s advocate and 57 providing requirements relating thereto; prohibiting a 58 direct care registered nurse from accepting an 59 assignment under specified circumstances; authorizing 60 a direct care registered nurse to refuse to accept an 61 assignment or to perform a task under certain 62 circumstances; requiring a direct care registered 63 nurse to initiate action or to change a decision or an 64 activity relating to a patient’s health care under 65 certain circumstances; prohibiting a health care 66 facility from discharging, or from discriminating, 67 retaliating, or filing a complaint or report against, 68 a direct care registered nurse based on such refusal; 69 providing that a direct care registered nurse has a 70 right of action against a health care facility that 71 violates certain provisions; requiring that the agency 72 establish a toll-free telephone hotline to provide 73 certain information and to receive reports of certain 74 violations; requiring that certain information be 75 provided to each patient who is admitted to a health 76 care facility; prohibiting a health care facility from 77 engaging in certain actions; prohibiting a health care 78 facility from interfering with the right of direct 79 care registered nurses to organize, bargain 80 collectively, and engage in concerted activity under a 81 federal act; authorizing the agency to impose fines 82 for violations; requiring that the agency post on its 83 website information regarding health care facilities 84 on which civil penalties have been imposed; providing 85 an effective date. 86 87 Be It Enacted by the Legislature of the State of Florida: 88 89 Section 1. Short title.—This act may be cited as the 90 “Florida Hospital Patient Protection Act.” 91 Section 2. Section 395.1014, Florida Statutes, is created 92 to read: 93 395.1014 Health care facility patient care standards.— 94 (1) LEGISLATIVE FINDINGS.—The Legislature finds that: 95 (a) The state has a substantial interest in ensuring that, 96 in the delivery of health care services to patients, health care 97 facilities retain sufficient nursing staff to promote optimal 98 health care outcomes. 99 (b) Health care services are becoming more complex and it 100 is increasingly difficult for patients to access integrated 101 services. Competent, safe, therapeutic, and effective patient 102 care is jeopardized because of staffing changes implemented in 103 response to market-driven managed care. To ensure effective 104 protection of patients in acute care settings, it is essential 105 that qualified direct care registered nurses be accessible and 106 available to meet the individual needs of the patient at all 107 times. Also, to ensure the health and welfare of residents and 108 to ensure that hospital nursing care is provided in the 109 exclusive interests of patients, mandatory practice standards 110 and professional practice protections for professional direct 111 care registered nursing staff must be established. Direct care 112 registered nurses have a duty to care for assigned patients and 113 a necessary duty of individual and collective patient advocacy 114 to satisfy professional obligations. 115 (c) The basic principles of staffing in hospital settings 116 should be based on the care needs of the individual patient, the 117 severity of the patient’s condition, the services needed, and 118 the complexity surrounding those services. Current unsafe 119 practices by hospital direct care registered nursing staff have 120 resulted in adverse patient outcomes. Mandating the adoption of 121 uniform, minimum, numerical, and specific direct care registered 122 nurse-to-patient staffing ratios by licensed hospital facilities 123 is necessary for competent, safe, therapeutic, and effective 124 professional nursing care and for the retention and recruitment 125 of qualified direct care registered nurses. 126 (d) Direct care registered nurses must be able to advocate 127 for their patients without fear of retaliation from their 128 employers. Whistle-blower protections that encourage direct care 129 registered nurses and patients to notify governmental and 130 private accreditation entities of suspected unsafe patient 131 conditions, including protection against retaliation for 132 refusing unsafe patient care assignments, will greatly enhance 133 the health, safety, and welfare of patients. 134 (e) Direct care registered nurses have an irrevocable duty 135 and right to advocate on behalf of their patients’ interests, 136 and this duty and right may not be encumbered by cost-saving 137 practices. 138 (2) DEFINITIONS.—As used in this section, the term: 139 (a) “Acuity-based patient classification system” or 140 “patient classification system” means an established measurement 141 tool that: 142 1. Predicts registered nursing care requirements for 143 individual patients based on the severity of a patient’s 144 illness; the need for specialized equipment and technology; the 145 intensity of required nursing interventions; the complexity of 146 clinical nursing judgment required to design, implement, and 147 evaluate the patient nursing care plan consistent with 148 professional standards; the ability for self-care, including 149 motor, sensory, and cognitive deficits; and the need for 150 advocacy intervention; 151 2. Details the amount of nursing care needed and the 152 additional number of direct care registered nurses and other 153 licensed and unlicensed nursing staff that the hospital must 154 assign, based on the independent professional judgment of a 155 direct care registered nurse, to meet the needs of individual 156 patients at all times; and 157 3. Can be readily understood and used by direct care 158 nursing staff. 159 (b) “Ancillary support staff” means the personnel assigned 160 to assist in providing nursing services for the delivery of 161 safe, therapeutic, and effective patient care, including unit or 162 ward clerks and secretaries; clinical technicians; respiratory 163 therapists; and radiology, laboratory, housekeeping, and dietary 164 personnel. 165 (c) “Clinical supervision” means the assignment and 166 direction of a patient care task required in the implementation 167 of nursing care for a patient to other licensed nursing staff or 168 to unlicensed staff by a direct care registered nurse in the 169 exclusive interests of the patient. 170 (d) “Competence” means the ability of a direct care 171 registered nurse to act and integrate the knowledge, skills, 172 abilities, and independent professional judgment that underpin 173 safe, therapeutic, and effective patient care. 174 (e) “Declared state of emergency” means an officially 175 designated state of emergency that has been declared by a 176 federal, state, or local government official who has the 177 authority to declare the state of emergency. The term does not 178 include a state of emergency that results from a labor dispute 179 in the health care industry. 180 (f) “Direct care registered nurse” means a registered nurse 181 or licensed practical nurse, as defined in s. 464.003: 182 1. Who is licensed by the Board of Nursing to engage in the 183 practice of professional nursing or the practice of practical 184 nursing, as defined in s. 464.003; 185 2. Whose competence has been documented; and 186 3. Who has accepted a direct, hands-on patient care 187 assignment to implement medical and nursing regimens and provide 188 related clinical supervision of patient care while exercising 189 independent professional judgment at all times in the exclusive 190 interests of the patient. 191 (g) “Health care facility unit” means an acute care 192 hospital; an emergency care, ambulatory, or outpatient surgery 193 facility licensed under this chapter; or a psychiatric facility 194 licensed under chapter 394. 195 (h) “Hospital unit” or “clinical unit” means an acuity 196 adjustable unit, critical care unit or intensive care unit, 197 labor and delivery unit, antepartum and postpartum unit, newborn 198 nursery, postanesthesia unit, emergency department, operating 199 room, pediatric unit, rehabilitation unit, skilled nursing unit, 200 specialty care unit, step-down unit or intermediate intensive 201 care unit, surgical unit, telemetry unit, or psychiatric unit. 202 1. “Acuity adjustable unit” means a unit that adjusts a 203 room’s technology, monitoring systems, and intensity of nursing 204 care based on the severity of the patient’s medical condition. 205 2. “Critical care unit” or “intensive care unit” means a 206 nursing unit established to safeguard and protect a patient 207 whose severity of medical condition requires continuous 208 monitoring and complex intervention by a direct care registered 209 nurse and whose restorative measures and level of nursing 210 intensity require intensive care through direct observation; 211 complex monitoring; intensive intricate assessment; evaluation; 212 specialized rapid intervention; and education or teaching of the 213 patient, the patient’s family, or other representatives by a 214 competent and experienced direct care registered nurse. The term 215 includes a burn unit, coronary care unit, or acute respiratory 216 unit. 217 3. “Rehabilitation unit” means a functional clinical unit 218 established to provide rehabilitation services that restore an 219 ill or injured patient to the highest level of self-sufficiency 220 or gainful employment of which he or she is capable in the 221 shortest possible time; compatible with his or her physical, 222 intellectual, and emotional or psychological capabilities; and 223 in accordance with planned goals and objectives. 224 4. “Skilled nursing unit” means a functional clinical unit 225 established to provide skilled nursing care and supportive care 226 to patients whose primary need is for skilled nursing care on a 227 long-term basis and who are admitted after at least a 48-hour 228 period of continuous inpatient care. The term includes, but is 229 not limited to, a unit established to provide medical, nursing, 230 dietary, and pharmaceutical services and activity programs. 231 5. “Specialty care unit” means a unit established to 232 safeguard and protect a patient whose severity of illness, 233 including all co-occurring morbidities, restorative measures, 234 and level of nursing intensity, requires continuous care through 235 direct observation and monitoring; multiple assessments; 236 specialized interventions; evaluations; and education or 237 teaching of the patient, the patient’s family, or other 238 representatives by a competent and experienced direct care 239 registered nurse. The term includes, but is not limited to, a 240 unit established to provide the intensity of care required for a 241 specific medical condition or a specific patient population or 242 to provide more comprehensive care for a specific condition or 243 disease than the care required in a surgical unit. 244 6. “Step-down unit” or “intermediate intensive care unit” 245 means a unit established to safeguard and protect a patient 246 whose severity of illness, including all co-occurring 247 morbidities, restorative measures, and level of nursing 248 intensity, requires intermediate intensive care through direct 249 observation and monitoring; multiple assessments; specialized 250 interventions; evaluations; and education or teaching of the 251 patient, the patient’s family, or other representatives by a 252 competent and experienced direct care registered nurse. The term 253 includes a unit established to provide care to patients who have 254 moderate or potentially severe physiological instability 255 requiring technical support, but not necessarily artificial life 256 support. As used in this subparagraph, the term: 257 a. “Artificial life support” means a system that uses 258 medical technology to aid, support, or replace a vital function 259 of the body which has been seriously damaged. 260 b. “Technical support” means the use of specialized 261 equipment by a direct care registered nurse in providing for 262 invasive monitoring, telemetry, and mechanical ventilation for 263 the immediate amelioration or remediation of severe pathology 264 for a patient requiring less care than intensive care, but more 265 care than the care provided in a surgical unit. 266 7. “Surgical unit” means a unit established to safeguard 267 and protect a patient whose severity of illness, including all 268 co-occurring morbidities, restorative measures, and level of 269 nursing intensity, requires continuous care through direct 270 observation and monitoring; multiple assessments; specialized 271 interventions; evaluations; and education or teaching of the 272 patient, the patient’s family, or other representatives by a 273 competent and experienced direct care registered nurse. The term 274 includes a unit established to provide care to patients who 275 require less than intensive care or step-down care; patients who 276 receive 24-hour inpatient general medical care or postsurgical 277 care, or both; and mixed populations of patients of diverse 278 diagnoses and diverse ages, excluding pediatric patients. 279 8. “Telemetry unit” means a unit established to safeguard 280 and protect a patient whose severity of illness, including all 281 co-occurring morbidities, restorative measures, and level of 282 nursing intensity, requires intermediate intensive care through 283 direct observation and monitoring; multiple assessments; 284 specialized interventions; evaluations; and education or 285 teaching of the patient, the patient’s family, or other 286 representatives by a competent and experienced direct care 287 registered nurse. The term includes a unit in which specialized 288 equipment is used to provide for the electronic monitoring, 289 recording, retrieval, and display of cardiac electrical signals. 290 (i) “Long-term acute care hospital” means a hospital or 291 health care facility that specializes in providing long-term 292 acute care to medically complex patients. The term includes a 293 freestanding and hospital-within-hospital model of a long-term 294 acute care facility. 295 (j) “Overtime” means the hours worked in excess of: 296 1. An agreed-upon, predetermined, regularly scheduled 297 shift; 298 2. Twelve hours in a 24-hour period; or 299 3. Eighty hours in a 14-day period. 300 (k) “Patient assessment” means the use of critical thinking 301 by a direct care registered nurse, and the intellectually 302 disciplined process of actively and skillfully interpreting, 303 applying, analyzing, synthesizing, or evaluating data obtained 304 through direct observation and communication with others. 305 (l) “Professional judgment” means the intellectual, 306 educated, informed, and experienced process that a direct care 307 registered nurse exercises in forming an opinion and reaching a 308 clinical decision that is in the exclusive interests of the 309 patient and is based upon the analysis of data, information, and 310 scientific evidence. 311 (m) “Skill mix” means the differences in licensing, 312 specialty, and experience among direct care registered nurses. 313 (3) MINIMUM DIRECT CARE REGISTERED NURSE STAFFING LEVEL 314 REQUIREMENTS.— 315 (a) A health care facility shall implement a staffing plan 316 that provides for a minimum direct care registered nurse 317 staffing level in accordance with the general requirements set 318 forth in this subsection and the direct care registered nurse 319 staffing levels in a clinical unit as specified in paragraph 320 (b). Staffing levels for patient care tasks that do not require 321 a direct care registered nurse are not included within these 322 ratios and shall be determined pursuant to an acuity-based 323 patient classification system defined by agency rule. 324 1. A health care facility may not assign a direct care 325 registered nurse to a clinical unit unless the health care 326 facility and the direct care registered nurse determine that 327 such nurse has demonstrated competence in providing care in the 328 clinical unit and has also received orientation in the clinical 329 unit’s area of specialty which is sufficient to provide 330 competent, safe, therapeutic, and effective care to a patient in 331 that unit. The policies and procedures of the health care 332 facility must contain the criteria for making this 333 determination. 334 2. The direct care registered nurse staffing levels 335 represent the maximum number of patients that may be assigned to 336 one direct care registered nurse at any one time. 337 3. A health care facility: 338 a. May not average the total number of patients and the 339 total number of direct care registered nurses assigned to 340 patients in a hospital unit or clinical unit during any period 341 for purposes of meeting the requirements under this subsection. 342 b. May not impose mandatory overtime in order to meet the 343 minimum direct care registered nurse staffing levels in the 344 hospital unit or clinical unit which are required under this 345 subsection. 346 c. Shall ensure that only a direct care registered nurse 347 may relieve another direct care registered nurse during breaks, 348 meals, and routine absences from a hospital unit or clinical 349 unit. 350 d. May not lay off licensed practical nurses, licensed 351 psychiatric technicians, certified nursing assistants, or other 352 ancillary support staff to meet the direct care registered nurse 353 staffing levels required in this subsection for a hospital unit 354 or clinical unit. 355 4. Only a direct care registered nurse may be assigned to 356 an intensive care newborn nursery service unit, which 357 specifically requires a direct care registered nurse staffing 358 level of one such nurse to two or fewer infants at all times. 359 5. In the emergency department, only a direct care 360 registered nurse may be assigned to a triage patient or a 361 critical care patient. 362 a. The direct care registered nurse staffing level for 363 triage patients or critical care patients in the emergency 364 department must be one such nurse to two or fewer patients at 365 all times. 366 b. At least two direct care registered nurses must be 367 physically present in the emergency department when a patient is 368 present. 369 c. Triage, radio, specialty, or flight registered nurses do 370 not count in the calculation of direct care registered nurse 371 staffing levels. Triage registered nurses may not be assigned 372 the responsibility of the base radio. 373 6. Only a direct care registered nurse may be assigned to a 374 labor and delivery unit. 375 a. The direct care registered nurse staffing level must be 376 one such nurse to one active labor patient, or one patient 377 having medical or obstetrical complications, during the 378 initiation of epidural anesthesia and during circulation for a 379 caesarean section delivery. 380 b. The direct care registered nurse staffing level for 381 antepartum patients who are not in active labor must be one such 382 nurse to three or fewer patients at all times. 383 c. In the event of a caesarean delivery, the direct care 384 registered nurse staffing level must be one such nurse to four 385 or fewer mother-plus-infant couplets. 386 d. In the event of multiple births, the direct care 387 registered nurse staffing level must be one such nurse to six or 388 fewer mother-plus-infant couplets. 389 e. The direct care registered nurse staffing level for 390 postpartum areas in which the direct care registered nurse’s 391 assignment consists of only mothers must be one such nurse to 392 four or fewer patients at all times. 393 f. The direct care registered nurse staffing level for 394 postpartum patients or postsurgical gynecological patients must 395 be one such nurse to four or fewer patients at all times. 396 g. The direct care registered nurse staffing level for the 397 well-baby nursery must be one such nurse to five or fewer 398 patients at all times. 399 h. The direct care registered nurse staffing level for 400 unstable newborns and newborns in the resuscitation period as 401 assessed by a direct care registered nurse must be at least one 402 such nurse to one patient at all times. 403 i. The direct care registered nurse staffing level for 404 newborns must be one such nurse to four or fewer patients at all 405 times. 406 7. The direct care registered nurse staffing level for 407 patients receiving conscious sedation must be at least one such 408 nurse to one patient at all times. 409 (b) A health care facility’s staffing plan must provide 410 that, at all times during each shift within a unit of the 411 facility, a direct care registered nurse is assigned to not more 412 than: 413 1. One patient in a trauma emergency unit; 414 2. One patient in an operating room unit. The operating 415 room must have at least one direct care registered nurse 416 assigned to the duties of the circulating registered nurse and a 417 minimum of one additional person as a scrub assistant for each 418 patient-occupied operating room; 419 3. Two patients in a critical care unit, including neonatal 420 intensive care units; emergency critical care and intensive care 421 units; labor and delivery units; coronary care units; acute 422 respiratory care units; postanesthesia units, regardless of the 423 type of anesthesia administered; and postpartum units, so that 424 the direct care registered nurse staffing level is one such 425 nurse to two or fewer patients at all times; 426 4. Three patients in an emergency room unit; step-down unit 427 or intermediate intensive care unit; pediatric unit; telemetry 428 unit; or combined labor and postpartum unit so that the direct 429 care registered nurse staffing level is one such nurse to three 430 or fewer patients at all times; 431 5. Four patients in a surgical unit, antepartum unit, 432 intermediate care nursery unit, psychiatric unit, or presurgical 433 or other specialty care unit so that the direct care registered 434 nurse staffing level is one such nurse to four or fewer patients 435 at all times; 436 6. Five patients in a rehabilitation unit or skilled 437 nursing unit so that the direct care registered nurse staffing 438 level is one such nurse to five or fewer patients at all times; 439 7. Six patients in a well-baby nursery unit so that the 440 direct care registered nurse staffing level is one such nurse to 441 six or fewer patients at all times; or 442 8. Three mother-plus-infant couplets in a postpartum unit 443 so that the direct care registered nurse staffing level is one 444 such nurse to three or fewer mother-plus-infant couplets at all 445 times. 446 (c)1. Identifying a hospital unit or clinical unit by a 447 name or term other than those defined in subsection (2) does not 448 affect the requirement of direct care registered nurse staffing 449 levels identified for the level of intensity or type of care 450 described in paragraphs (a) and (b). 451 2. Patients shall be cared for only in hospital units or 452 clinical units in which the level of intensity, type of care, 453 and direct care registered nurse staffing levels meet the 454 individual requirements and needs of each patient. A health care 455 facility may not use an acuity adjustable unit to care for a 456 patient. 457 3. A health care facility may not use a video camera or 458 monitor or any form of electronic visualization of a patient to 459 substitute for the direct observation required for patient 460 assessment by the direct care registered nurse and for patient 461 protection provided by an attendant. 462 (d) The requirements established under this subsection do 463 not apply during a declared state of emergency, as defined in 464 subsection (2), if a health care facility is requested or 465 expected to provide an exceptional level of emergency or other 466 medical services. 467 (e) The chief nursing officer or his or her designee shall 468 develop a staffing plan for each hospital unit or clinical unit. 469 1. The staffing plan must be in writing and, based on 470 individual patient care needs determined by the acuity-based 471 patient classification system, must specify individual patient 472 care requirements and the staffing levels for direct care 473 registered nurses and other licensed and unlicensed personnel. 474 The direct care registered nurse staffing level on any shift may 475 not fall below the requirements in paragraphs (a) and (b) at any 476 time. 477 2. In addition to the requirements of direct care 478 registered nurse staffing levels in paragraphs (a) and (b), each 479 health care facility shall assign additional nursing staff, 480 including, but not limited to, licensed practical nurses, 481 licensed psychiatric technicians, and certified nursing 482 assistants, through the implementation of a valid acuity-based 483 patient classification system for determining nursing care needs 484 of individual patients which reflects the assessment of patient 485 nursing care requirements made by the assigned direct care 486 registered nurse and which provides for shift-by-shift staffing 487 based on those requirements. The direct care registered nurse 488 staffing levels specified in paragraphs (a) and (b) constitute 489 the minimum number of direct care registered nurses who shall be 490 assigned to provide direct patient care. 491 3. In developing the staffing plan, a health care facility 492 shall provide for direct care registered nurse staffing levels 493 that are above the minimum levels required in paragraphs (a) and 494 (b) based upon consideration of the following factors: 495 a. The number of patients and their acuity levels as 496 determined by the application of a patient classification system 497 on a shift-by-shift basis. 498 b. The anticipated admissions, discharges, and transfers of 499 patients during each shift which affect direct patient care. 500 c. The specialized experience required of direct care 501 registered nurses on a particular hospital unit or clinical 502 unit. 503 d. Staffing levels of other health care personnel who 504 provide direct patient care services for patients who normally 505 do not require care by a direct care registered nurse. 506 e. The level of efficacy of technology that is available 507 that affects the delivery of direct patient care. 508 f. The level of familiarity with hospital practices, 509 policies, and procedures by a direct care registered nurse from 510 a temporary agency during a shift. 511 g. Obstacles to efficiency in the delivery of patient care 512 caused by the physical layout of the health care facility. 513 4. A health care facility shall specify the acuity-based 514 patient classification system used to document actual staffing 515 in each unit for each shift. 516 5. A health care facility shall annually evaluate: 517 a. The reliability of the acuity-based patient 518 classification system for validating staffing requirements to 519 determine whether such system accurately measures individual 520 patient care needs and accurately predicts the staffing 521 requirements for direct care registered nurses, licensed 522 practical nurses, licensed psychiatric technicians, and 523 certified nursing assistants, based exclusively on individual 524 patient needs. 525 b. The validity of the acuity-based patient classification 526 system. 527 6. A health care facility shall annually update its 528 staffing plan and acuity-based patient classification system to 529 the extent appropriate based on the annual evaluation conducted 530 under subparagraph 5. If the evaluation reveals that adjustments 531 are necessary to ensure accuracy in measuring patient care 532 needs, such adjustments must be implemented within 30 days after 533 such determination. 534 7. Any acuity-based patient classification system adopted 535 by a health care facility under this subsection must be 536 transparent in all respects, including disclosure of detailed 537 documentation of the methodology used to predict nurse staffing; 538 an identification of each factor, assumption, and value used in 539 applying such methodology; an explanation of the scientific and 540 empirical basis for each such assumption and value; and 541 certification by a knowledgeable and authorized representative 542 of the health care facility that the disclosures regarding 543 methods used for testing and validating the accuracy and 544 reliability of such system are true and complete. 545 a. The documentation required by this subparagraph shall be 546 submitted in its entirety to the agency as a mandatory condition 547 of licensure, with a certification by the chief nursing officer 548 of the health care facility that the documentation completely 549 and accurately reflects implementation of a valid acuity-based 550 patient classification system used to determine nurse staffing 551 by the facility for each shift in each hospital unit or clinical 552 unit in which patients receive care. The chief nursing officer 553 shall execute the certification under penalty of perjury, and 554 the certification must contain an expressed acknowledgment that 555 any false statement constitutes fraud and is subject to criminal 556 and civil prosecution and penalties. 557 b. Such documentation must be available for public 558 inspection in its entirety in accordance with procedures 559 established by administrative rules adopted by the agency, 560 consistent with the purposes of this section. 561 8. A staffing plan of a health care facility shall be 562 developed and evaluated by a committee created by the health 563 care facility. At least half of the members of the committee 564 must be unit-specific competent direct care registered nurses. 565 a. The chief nursing officer at the facility shall appoint 566 the members who are not direct care registered nurses. The 567 direct care registered nurses on the committee shall be 568 appointed by the chief nursing officer if the direct care 569 registered nurses are not represented by a collective bargaining 570 agreement or by an authorized collective bargaining agent. 571 b. In case of a dispute, the direct care registered nurse 572 assessment shall prevail. 573 c. This section does not authorize conduct that is 574 prohibited under the National Labor Relations Act or the Federal 575 Labor Relations Act of 1978. 576 9. By July 1, 2020, the agency shall approve uniform 577 statewide standards for a standardized acuity tool for use in 578 health care facilities. The standardized acuity tool must 579 provide a method for establishing direct care registered nurse 580 staffing requirements that exceed the required direct care 581 registered nurse staffing levels in the hospital units or 582 clinical units in paragraphs (a) and (b). 583 a. The proposed standards shall be developed by a committee 584 created by the health care facility consisting of up to 20 585 members. At least 11 of the committee members must be registered 586 nurses who are currently licensed and employed as direct care 587 registered nurses, and the remaining committee members must 588 include a sufficient number of technical or scientific experts 589 in specialized fields who are involved in the design and 590 development of an acuity-based patient classification system 591 that meets the requirements of this section. 592 b. A person who has any employment or any commercial, 593 proprietary, financial, or other personal interest in the 594 development, marketing, or use of a private patient 595 classification system product or related methodology, 596 technology, or component system is not eligible to serve on the 597 committee. A candidate for appointment to the committee may not 598 be confirmed as a member until the candidate files a disclosure 599 of-interest statement with the agency, along with a signed 600 certification of full disclosure and complete accuracy under 601 oath, which provides all necessary information as determined by 602 the agency to demonstrate the absence of actual or potential 603 conflict of interest. All such filings are subject to public 604 inspection. 605 c. Within 1 year after the official commencement of 606 committee operations, the committee shall provide a written 607 report to the agency that proposes uniform standards for a 608 valid, acuity-based patient classification system, along with a 609 sufficient explanation and justification to allow for competent 610 review and determination of sufficiency by the agency. The 611 agency shall disclose the report to the public upon notice of 612 public hearings and provide a public comment period for proposed 613 adoption of uniform standards for an acuity-based patient 614 classification system by the agency. 615 10. A hospital shall adopt and implement the acuity-based 616 patient classification system and provide staffing based on the 617 standardized acuity tool. Any additional direct care registered 618 nurse staffing level that exceeds the direct care registered 619 nurse staffing levels described in paragraphs (a) and (b) shall 620 be assigned in a manner determined by such standardized acuity 621 tool. 622 11. A health care facility shall submit to the agency its 623 annually updated staffing plan and acuity-based patient 624 classification system as required under this paragraph. 625 (f)1. In each hospital unit or clinical unit, a health care 626 facility shall post a notice in a form specified by agency rule 627 that: 628 a. Explains the requirements imposed under this subsection; 629 b. Includes actual direct care registered nurse staffing 630 levels during each shift at the hospital unit or clinical unit; 631 c. Is visible, conspicuous, and accessible to staff and 632 patients of the hospital unit or clinical unit and the public; 633 d. Identifies staffing requirements as determined by the 634 acuity-based patient classification system for each hospital 635 unit or clinical unit, documented and posted in the unit for 636 public view on a day-to-day, shift-by-shift basis; 637 e. Documents the actual number of staff and the skill mix 638 of such staff in each hospital unit or clinical unit, documented 639 and posted in the unit for public view on a day-to-day, shift 640 by-shift basis; and 641 f. Reports the variance between the required and actual 642 staffing patterns in each hospital unit or clinical unit, 643 documented and posted in the unit for public view on a day-to 644 day, shift-by-shift basis. 645 2.a. A long-term acute care hospital shall maintain 646 accurate records of actual staffing levels in each hospital unit 647 or clinical unit for each shift for at least 2 years. Such 648 records must include: 649 (I) The number of patients in each unit; 650 (II) The identity and duty hours of each direct care 651 registered nurse, licensed practical nurse, licensed psychiatric 652 technician, and certified nursing assistant assigned to each 653 patient in the hospital unit or clinical unit for each shift; 654 and 655 (III) A copy of each posted notice. 656 b. A health care facility shall make its staffing plan and 657 acuity-based patient classification system required under 658 paragraph (e), and all documentation related to such plan and 659 system, available to the agency; to direct care registered 660 nurses and their collective bargaining representatives, if any; 661 and to the public under rules adopted by the agency. 662 3. The agency shall conduct periodic audits to ensure 663 implementation of the staffing plan in accordance with this 664 subsection and to ensure the accuracy of the staffing plan and 665 the acuity-based patient classification system required under 666 paragraph (e). 667 (g) A health care facility shall plan for routine 668 fluctuations such as admissions, discharges, and transfers in 669 the patient census. If a declared state of emergency causes a 670 change in the number of patients in a unit, the health care 671 facility must demonstrate that immediate and diligent efforts 672 are made to maintain required staffing levels. 673 (h) The following activities are prohibited: 674 1. The direct assignment of unlicensed personnel by a 675 health care facility to perform functions required of a direct 676 care registered nurse in lieu of care being delivered by a 677 licensed or registered nurse under the clinical supervision of a 678 direct care registered nurse. 679 2. The performance of patient care tasks by unlicensed 680 personnel that require the clinical assessment, judgment, and 681 skill of a licensed or registered nurse, including, but not 682 limited to: 683 a. Nursing activities that require nursing assessment and 684 judgment during implementation; 685 b. Physical, psychological, or social assessments that 686 require nursing judgment, intervention, referral, or followup; 687 and 688 c. Formulation of a plan of nursing care and evaluation of 689 a patient’s response to the care provided, including 690 administration of medication; venipuncture or intravenous 691 therapy; parenteral or tube feedings; invasive procedures, 692 including inserting nasogastric tubes, inserting catheters, or 693 tracheal suctioning; and educating a patient and the patient’s 694 family concerning the patient’s health care problems, including 695 postdischarge care. However, a phlebotomist, emergency room 696 technician, or medical technician may, under the general 697 supervision of the clinical laboratory director, or his or her 698 designee, or a physician, perform venipunctures in accordance 699 with written hospital policies and procedures. 700 (4) PROFESSIONAL PRACTICE STANDARDS FOR DIRECT CARE 701 REGISTERED NURSES WORKING IN A HEALTH CARE FACILITY.— 702 (a) A direct care registered nurse employing scientific 703 knowledge and experience in the physical, social, and biological 704 sciences, and exercising independent judgment in applying the 705 nursing process, shall directly provide: 706 1. Continuous and ongoing assessments of the patient’s 707 condition. 708 2. The planning, clinical supervision, implementation, and 709 evaluation of the nursing care provided to each patient. 710 3. The assessment, planning, implementation, and evaluation 711 of patient education, including the ongoing postdischarge 712 education of each patient. 713 4. The delivery of patient care, which must reflect all 714 elements of the nursing process and must include assessment, 715 nursing diagnosis, planning, intervention, evaluation, and, as 716 circumstances require, patient advocacy, and shall be initiated 717 by a direct care registered nurse at the time of admission. 718 5. The nursing plan for the patient care, which shall be 719 discussed with and developed as a result of coordination with 720 the patient, the patient’s family or other representatives, when 721 appropriate, and the staff of other disciplines involved in the 722 care of the patient. 723 6. An evaluation of the effectiveness of the care plan 724 through assessments based on direct observation of the patient’s 725 physical condition and behavior, signs and symptoms of illness, 726 and reactions to treatment, and through communication with the 727 patient and the health care team members, and modification of 728 the plan as needed. 729 7. Information related to the initial assessment and 730 reassessments of the patient, nursing diagnosis, plan, 731 intervention, evaluation, and patient advocacy, which shall be 732 permanently recorded in the patient’s medical record as 733 narrative direct care progress notes. The practice of charting 734 by exception is prohibited. 735 (b)1. A patient assessment requires direct observation of 736 the patient’s signs and symptoms of illness, reaction to 737 treatment, behavior and physical condition, and interpretation 738 of information obtained from the patient and others, including 739 the health care team members. A patient assessment requires data 740 collection by a direct care registered nurse and the analysis, 741 synthesis, and evaluation of such data. 742 2. Only a direct care registered nurse may perform a 743 patient assessment. A licensed practical nurse or licensed 744 psychiatric technician may assist a direct care registered nurse 745 in data collection. 746 (c)1. A direct care registered nurse shall determine the 747 nursing care needs of individual patients through the process of 748 ongoing patient assessments, nursing diagnosis, formulation, and 749 adjustment of nursing care plans. 750 2. The prediction of individual patient nursing care needs 751 for prospective assignment of direct care registered nurses 752 shall be based on individual patient assessments of the direct 753 care registered nurse assigned to each patient and in accordance 754 with a documented acuity-based patient classification system as 755 required in subsection (3). 756 (d) Competent performance of the essential functions of a 757 direct care registered nurse as provided in this section 758 requires the exercise of independent judgment in the exclusive 759 interests of the patient. A direct care registered nurse’s 760 independent judgment while performing the functions described in 761 this section shall be provided in the exclusive interests of the 762 patient and may not, for any purpose, be considered, relied 763 upon, or represented as a job function, authority, 764 responsibility, or activity undertaken in any respect for the 765 purpose of serving the business, commercial, operational, or 766 other institutional interests of the health care facility 767 employer. 768 (e)1. In addition to the prohibition on assignments of 769 patient care tasks provided in paragraph (3)(h), a direct care 770 registered nurse may not assign tasks required to implement 771 nursing care for a patient to other licensed nursing staff or to 772 unlicensed staff unless the assigning direct care registered 773 nurse: 774 a. Determines that the personnel assigned the nursing care 775 tasks possess the necessary training, experience, and capability 776 to competently and safely perform such tasks; and 777 b. Effectively supervises the clinical functions and 778 nursing care tasks performed by the assigned personnel. 779 2. The exercise of clinical supervision of nursing care 780 personnel by a direct care registered nurse in the performance 781 of the functions as provided in this subsection must be in the 782 exclusive interests of the patient and may not, for any purpose, 783 be considered, relied upon, or represented as a job function, 784 authority, responsibility, or activity undertaken in any respect 785 for the purpose of serving the business, commercial, 786 operational, or other institutional interests of the health care 787 facility employer, but constitutes the exercise of professional 788 nursing authority and duty in the exclusive interests of the 789 patient. 790 (f) A health care facility may not deploy technology that 791 limits the direct care provided by a direct care registered 792 nurse in the performance of functions that are part of the 793 nursing process, including the full exercise of independent 794 professional judgment in the assessment, planning, 795 implementation, and evaluation of care, or that limits a direct 796 care registered nurse from acting as a patient advocate in the 797 exclusive interests of the patient. Technology may not be skill 798 degrading, interfere with the direct care registered nurse’s 799 provision of individualized patient care, or override the direct 800 care registered nurse’s independent professional judgment. 801 (g) This subsection applies only to direct care registered 802 nurses employed by or providing care in a health care facility. 803 (5) DIRECT CARE REGISTERED NURSE’S DUTY AND RIGHT OF 804 PATIENT ADVOCACY.— 805 (a) A direct care registered nurse has a duty and right to 806 act and provide care in the exclusive interests of the patient 807 and to act as the patient’s advocate. 808 (b) A direct care registered nurse shall always provide 809 competent, safe, therapeutic, and effective nursing care to an 810 assigned patient. 811 1. Before accepting a patient assignment, a direct care 812 registered nurse must have the necessary knowledge, judgment, 813 skills, and ability to provide the required care. It is the 814 responsibility of the direct care registered nurse to determine 815 whether he or she is clinically competent to perform the nursing 816 care required by a patient who is in a particular clinical unit 817 or who has a particular diagnosis, condition, prognosis, or 818 other determinative characteristic of nursing care, and whether 819 acceptance of a patient assignment would expose the patient to 820 the risk of harm. 821 2. If the direct care registered nurse is not competent to 822 perform the care required for a patient assigned for nursing 823 care or if the assignment would expose the patient to risk of 824 harm, the direct care registered nurse may not accept the 825 patient care assignment. Such refusal to accept a patient care 826 assignment is an exercise of the direct care registered nurse’s 827 duty and right of patient advocacy. 828 (c) A direct care registered nurse may refuse to accept an 829 assignment as a nurse in a health care facility if: 830 1. The assignment would violate chapter 464 or rules 831 adopted thereunder; 832 2. The assignment would violate subsection (3), subsection 833 (4), or this subsection; or 834 3. The direct care registered nurse is not prepared by 835 education, training, or experience to fulfill the assignment 836 without compromising the safety of a patient or jeopardizing the 837 license of the direct care registered nurse. 838 (d) A direct care registered nurse may refuse to perform an 839 assigned task as a nurse in a health care facility if: 840 1. The assigned task would violate chapter 464 or rules 841 adopted thereunder; 842 2. The assigned task is outside the scope of practice of 843 the direct care registered nurse; or 844 3. The direct care registered nurse is not prepared by 845 education, training, or experience to fulfill the assigned task 846 without compromising the safety of a patient or jeopardizing the 847 license of the direct care registered nurse. 848 (e) In the course of performing the responsibilities and 849 essential functions described in subsection (4), the direct care 850 registered nurse assigned to a patient shall receive orders 851 initiated by physicians and other legally authorized health care 852 professionals within their scope of licensure regarding patient 853 care services to be provided to the patient, including, but not 854 limited to, the administration of medications and therapeutic 855 agents that are necessary to implement a treatment, a 856 rehabilitative regimen, or disease prevention. 857 1. The direct care registered nurse shall assess each such 858 order before implementation to determine if the order is: 859 a. In the exclusive interests of the patient; 860 b. Initiated by a person legally authorized to issue the 861 order; and 862 c. Issued in accordance with the applicable laws and rules 863 governing nursing care. 864 2. If the direct care registered nurse determines that the 865 criteria provided in subparagraph 1. have not been satisfied 866 with respect to a particular order or if the direct care 867 registered nurse has some doubt regarding the meaning or 868 conformance of the order with such criteria, he or she shall 869 seek clarification from the initiator of the order, the 870 patient’s physician, or another appropriate medical officer 871 before implementing the order. 872 3. If, upon clarification, the direct care registered nurse 873 determines that the criteria for implementation of an order 874 provided in subparagraph 1. have not been satisfied, the direct 875 care registered nurse may refuse implementation on the basis 876 that the order is not in the exclusive interests of the patient. 877 Seeking clarification of an order or refusing an order as 878 described in this subparagraph is an exercise of the direct care 879 registered nurse’s duty and right of patient advocacy. 880 (f) A direct care registered nurse shall, as circumstances 881 require, initiate action to improve the patient’s health care or 882 to change a decision or activity that, in the professional 883 judgment of the direct care registered nurse, is against the 884 exclusive interests or desires of the patient or shall give the 885 patient the opportunity to make informed decisions about the 886 health care before it is provided. 887 (6) FREE SPEECH; PATIENT PROTECTION.— 888 (a) A health care facility may not: 889 1. Discharge, discriminate against, or retaliate against in 890 any manner with respect to any aspect of employment, including 891 discharge, promotion, compensation, or terms, conditions, or 892 privileges of employment, a direct care registered nurse based 893 on the direct care registered nurse’s refusal to accept an 894 assignment pursuant to paragraph (5)(c) or an assigned task 895 pursuant to paragraph (5)(d). 896 2. File a complaint or a report against a direct care 897 registered nurse with the Board of Nursing or the agency because 898 of the direct care registered nurse’s refusal of an assignment 899 pursuant to paragraph (5)(c) or an assigned task pursuant to 900 paragraph (5)(d). 901 (b) A direct care registered nurse who has been discharged, 902 discriminated against, or retaliated against in violation of 903 subparagraph (a)1. or against whom a complaint or a report has 904 been filed in violation of subparagraph (a)2. may bring a cause 905 of action in a court of competent jurisdiction. A direct care 906 registered nurse who prevails in the cause of action is entitled 907 to one or more of the following: 908 1. Reinstatement. 909 2. Reimbursement of lost wages, compensation, and benefits. 910 3. Attorney fees. 911 4. Court costs. 912 5. Other damages. 913 (c) A direct care registered nurse, a patient, or any other 914 individual may file a complaint with the agency against a health 915 care facility that violates this section. For any complaint 916 filed, the agency shall: 917 1. Receive and investigate the complaint; 918 2. Determine whether a violation of this section as alleged 919 in the complaint has occurred; and 920 3. If such a violation has occurred, issue an order 921 prohibiting the health care facility from subjecting the 922 complaining direct care registered nurse, the patient, or the 923 other individual to any retaliation described in paragraph (a). 924 (d)1. A health care facility may not discriminate or 925 retaliate in any manner against any patient, employee, or 926 contract employee of the facility, or any other individual, on 927 the basis that such individual, in good faith, individually or 928 in conjunction with another person or persons, has presented a 929 grievance or complaint; initiated or cooperated in an 930 investigation or proceeding by a governmental entity, regulatory 931 agency, or private accreditation body; made a civil claim or 932 demand; or filed an action relating to the care, services, or 933 conditions of the health care facility or of any affiliated or 934 related facilities. 935 2. For purposes of this paragraph, an individual is deemed 936 to be acting in good faith if the individual reasonably believes 937 that the information reported or disclosed is true. 938 (e)1. A health care facility may not: 939 a. Interfere with, restrain, or deny the exercise of, or 940 the attempt to exercise, any right provided or protected under 941 this section; or 942 b. Coerce or intimidate any person regarding the exercise 943 of, or the attempt to exercise, such right. 944 2. A health care facility may not discriminate or retaliate 945 against any person for opposing any facility policy, practice, 946 or action that is alleged to violate, breach, or fail to comply 947 with this section. 948 3. A health care facility, or an individual representing a 949 health care facility, may not make, adopt, or enforce any rule, 950 regulation, policy, or practice that in any manner directly or 951 indirectly prohibits, impedes, or discourages a direct care 952 registered nurse from engaging in free speech or disclosing 953 information as provided under this section. 954 4. A health care facility, or an individual representing a 955 health care facility, may not in any way interfere with the 956 rights of direct care registered nurses to organize, bargain 957 collectively, and engage in concerted activity under s. 7 of the 958 National Labor Relations Act. 959 5. A health care facility shall post in an appropriate 960 location in each hospital unit or clinical unit a notice in a 961 form specified by the agency that: 962 a. Explains the rights of nurses, patients, and other 963 individuals under this subsection; 964 b. Includes a statement that a nurse, patient, or other 965 individual may file a complaint with the agency against a health 966 care facility that violates this subsection; and 967 c. Provides instructions on how to file a complaint. 968 (f)1. The agency shall establish a toll-free telephone 969 hotline to provide information regarding the requirements of 970 this section and to receive reports of violations of this 971 section. 972 2. A health care facility shall provide each patient 973 admitted to the facility for inpatient care with the toll-free 974 telephone hotline described in subparagraph 1. and shall give 975 notice to each patient that the hotline may be used to report 976 inadequate staffing or care. 977 (7) ENFORCEMENT.— 978 (a) In addition to any other penalty prescribed by law, the 979 agency may impose civil penalties as follows: 980 1. Against a health care facility that violates this 981 section, a civil penalty of up to $25,000 for each violation, 982 except that the agency shall impose a civil penalty of at least 983 $25,000 for each violation if the agency determines that the 984 health care facility has a pattern of such violation. 985 2. Against an individual who is employed by a health care 986 facility who violates this section, a civil penalty of up to 987 $20,000 for each violation. 988 (b) The agency shall post on its website the names of 989 health care facilities against which civil penalties have been 990 imposed under this subsection and such additional information as 991 the agency deems necessary. 992 Section 3. This act shall take effect July 1, 2019.