Florida Senate - 2020 SB 204 By Senator Braynon 35-00171-20 2020204__ 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 other specified 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; requiring a 36 committee to develop and evaluate a staffing plan for 37 each health care facility within a specified 38 timeframe; providing requirements for committee 39 membership; requiring health care facilities to 40 annually report certain information to the agency and 41 to post a notice containing such information in each 42 unit of the facility; providing recordkeeping 43 requirements; prohibiting a health care facility from 44 assigning unlicensed personnel to perform functions or 45 tasks that should be performed by a licensed or 46 registered nurse; specifying those actions that 47 constitute professional practice by a direct care 48 registered nurse; providing requirements for patient 49 assessment and requiring that such assessment be 50 performed only by a direct care registered nurse; 51 authorizing a direct care registered nurse to assign 52 certain specified activities to other licensed or 53 unlicensed nursing staff under certain circumstances; 54 prohibiting a health care facility from deploying 55 technology that limits certain care provided by a 56 direct care registered nurse; providing applicability; 57 providing that it is a duty and right of a direct care 58 registered nurse to act as the patient’s advocate and 59 providing requirements relating thereto; prohibiting a 60 direct care registered nurse from accepting an 61 assignment under specified circumstances; authorizing 62 a direct care registered nurse to refuse to accept an 63 assignment or to perform a task under certain 64 circumstances; requiring a direct care registered 65 nurse to initiate action or to change a decision or an 66 activity relating to a patient’s health care under 67 certain circumstances; prohibiting a health care 68 facility from discharging, or from discriminating, 69 retaliating, or filing a complaint or report against, 70 a direct care registered nurse based on such refusal; 71 authorizing a direct care registered nurse to bring a 72 cause of action under certain circumstances; 73 authorizing certain entities to file a complaint with 74 the agency against a health care facility under 75 certain circumstances; requiring the agency to 76 investigate such complaints and issue certain orders 77 if certain findings are made; prohibiting a health 78 care facility from discriminating or retaliating 79 against those entities making such complaints; 80 prohibiting a health care facility from taking certain 81 actions in certain situations; prohibiting a health 82 care facility from interfering with the right of 83 direct care registered nurses to organize, bargain 84 collectively, and engage in concerted activity under a 85 federal act; requiring a health care facility to post 86 a certain notice in each hospital or clinical unit; 87 requiring that the agency establish a toll-free 88 telephone hotline to provide certain information and 89 to receive reports of certain violations; requiring 90 that certain information be provided to each patient 91 who is admitted to a health care facility; authorizing 92 the agency to impose fines for violations; requiring 93 that the agency post on its website information 94 regarding health care facilities on which civil 95 penalties have been imposed; providing an effective 96 date. 97 98 Be It Enacted by the Legislature of the State of Florida: 99 100 Section 1. Short title.—This act may be cited as the 101 “Florida Hospital Patient Protection Act.” 102 Section 2. Section 395.1014, Florida Statutes, is created 103 to read: 104 395.1014 Health care facility patient care standards.— 105 (1) LEGISLATIVE FINDINGS.—The Legislature finds that: 106 (a) The state has a substantial interest in ensuring that, 107 in the delivery of health care services to patients, health care 108 facilities retain sufficient nursing staff to promote optimal 109 health care outcomes. 110 (b) Health care services are becoming more complex, and it 111 is increasingly difficult for patients to access integrated 112 services. Competent, safe, therapeutic, and effective patient 113 care is jeopardized because of staffing changes implemented in 114 response to market-driven managed care. To ensure effective 115 protection of patients in acute care settings, it is essential 116 that qualified direct care registered nurses be accessible and 117 available to meet the individual needs of the patient at all 118 times. Also, to ensure the health and welfare of residents and 119 to ensure that hospital nursing care is provided in the 120 exclusive interests of patients, mandatory practice standards 121 and professional practice protections for professional direct 122 care registered nursing staff must be established. Direct care 123 registered nurses have a duty to care for assigned patients and 124 a necessary duty of individual and collective patient advocacy 125 to satisfy professional obligations. 126 (c) The basic principles of staffing in hospital settings 127 should be based on the care needs of the individual patient, the 128 severity of the patient’s condition, the services needed, and 129 the complexity surrounding those services. Current unsafe 130 practices by hospital direct care registered nursing staff have 131 resulted in adverse patient outcomes. Mandating the adoption of 132 uniform, minimum, numerical, and specific direct care registered 133 nurse-to-patient staffing ratios by licensed hospital facilities 134 is necessary for competent, safe, therapeutic, and effective 135 professional nursing care and for the retention and recruitment 136 of qualified direct care registered nurses. 137 (d) Direct care registered nurses must be able to advocate 138 for their patients without fear of retaliation from their 139 employers. Whistle-blower protections that encourage direct care 140 registered nurses and patients to notify governmental and 141 private accreditation entities of suspected unsafe patient 142 conditions, including protection against retaliation for 143 refusing unsafe patient care assignments, will greatly enhance 144 the health, safety, and welfare of patients. 145 (e) Direct care registered nurses have an irrevocable duty 146 and right to advocate on behalf of their patients’ interests, 147 and this duty and right may not be encumbered by cost-saving 148 practices. 149 (2) DEFINITIONS.—As used in this section, the term: 150 (a) “Acuity-based patient classification system” or 151 “patient classification system” means an established measurement 152 tool that: 153 1. Predicts registered nursing care requirements for 154 individual patients based on the severity of a patient’s 155 illness; the need for specialized equipment and technology; the 156 intensity of required nursing interventions; the complexity of 157 clinical nursing judgment required to design, implement, and 158 evaluate the patient nursing care plan consistent with 159 professional standards; the ability for self-care, including 160 motor, sensory, and cognitive deficits; and the need for 161 advocacy intervention; 162 2. Details the amount of nursing care needed and the 163 additional number of direct care registered nurses and other 164 licensed and unlicensed nursing staff that the hospital must 165 assign, based on the independent professional judgment of a 166 direct care registered nurse, to meet the needs of individual 167 patients at all times; and 168 3. Can be readily understood and used by direct care 169 nursing staff. 170 (b) “Ancillary support staff” means the personnel assigned 171 to assist in providing nursing services for the delivery of 172 safe, therapeutic, and effective patient care, including unit or 173 ward clerks and secretaries; clinical technicians; respiratory 174 therapists; and radiology, laboratory, housekeeping, and dietary 175 personnel. 176 (c) “Clinical supervision” means the assignment and 177 direction of a patient care task required in the implementation 178 of nursing care for a patient to other licensed nursing staff or 179 to unlicensed staff by a direct care registered nurse in the 180 exclusive interests of the patient. 181 (d) “Competence” means the ability of a direct care 182 registered nurse to act upon and integrate the knowledge, 183 skills, abilities, and independent professional judgment that 184 underpin safe, therapeutic, and effective patient care. 185 (e) “Declared state of emergency” means an officially 186 designated state of emergency that has been declared by a 187 federal, state, or local government official who has the 188 authority to declare the state of emergency. The term does not 189 include a state of emergency that results from a labor dispute 190 in the health care industry. 191 (f) “Direct care registered nurse” means a registered nurse 192 or licensed practical nurse, as defined in s. 464.003: 193 1. Who is licensed by the Board of Nursing to engage in the 194 practice of professional nursing or the practice of practical 195 nursing, as defined in s. 464.003; 196 2. Whose competence has been documented; and 197 3. Who has accepted a direct, hands-on patient care 198 assignment to implement medical and nursing regimens and provide 199 related clinical supervision of patient care while exercising 200 independent professional judgment at all times in the exclusive 201 interests of the patient. 202 (g) “Health care facility unit” means an acute care 203 hospital; an emergency care, ambulatory, or outpatient surgery 204 facility licensed under this chapter; or a psychiatric facility 205 licensed under chapter 394. 206 (h) “Hospital unit” or “clinical unit” means an acuity 207 adjustable unit, critical care unit or intensive care unit, 208 labor and delivery unit, antepartum and postpartum unit, newborn 209 nursery, postanesthesia unit, emergency department, operating 210 room, pediatric unit, rehabilitation unit, skilled nursing unit, 211 specialty care unit, step-down unit or intermediate intensive 212 care unit, surgical unit, telemetry unit, or psychiatric unit. 213 1. “Acuity-adjustable unit” means a unit that adjusts a 214 room’s technology, monitoring systems, and intensity of nursing 215 care based on the severity of the patient’s medical condition. 216 2. “Critical care unit” or “intensive care unit” means a 217 nursing unit established to safeguard and protect a patient 218 whose severity of medical condition requires continuous 219 monitoring and complex intervention by a direct care registered 220 nurse and whose restorative measures and level of nursing 221 intensity require intensive care through direct observation; 222 complex monitoring; intensive intricate assessment; evaluation; 223 specialized rapid intervention; and education or teaching of the 224 patient, the patient’s family, or other representatives by a 225 competent and experienced direct care registered nurse. The term 226 includes a burn unit, coronary care unit, or acute respiratory 227 unit. 228 3. “Rehabilitation unit” means a functional clinical unit 229 established to provide rehabilitation services that restore an 230 ill or injured patient to the highest level of self-sufficiency 231 or gainful employment of which he or she is capable in the 232 shortest possible time; compatible with his or her physical, 233 intellectual, and emotional or psychological capabilities; and 234 in accordance with planned goals and objectives. 235 4. “Skilled nursing unit” means a functional clinical unit 236 established to provide skilled nursing care and supportive care 237 to patients whose primary need is for skilled nursing care on a 238 long-term basis and who are admitted after at least a 48-hour 239 period of continuous inpatient care. The term includes, but is 240 not limited to, a unit established to provide medical, nursing, 241 dietary, and pharmaceutical services and activity programs. 242 5. “Specialty care unit” means a unit established to 243 safeguard and protect a patient whose severity of illness, 244 including all co-occurring morbidities, restorative measures, 245 and level of nursing intensity, requires continuous care through 246 direct observation and monitoring; multiple assessments; 247 specialized interventions; evaluations; and education or 248 teaching of the patient, the patient’s family, or other 249 representatives by a competent and experienced direct care 250 registered nurse. The term includes, but is not limited to, a 251 unit established to provide the intensity of care required for a 252 specific medical condition or a specific patient population or 253 to provide more comprehensive care for a specific condition or 254 disease than the care required in a surgical unit. 255 6. “Step-down unit” or “intermediate intensive care unit” 256 means a unit established to safeguard and protect a patient 257 whose severity of illness, including all co-occurring 258 morbidities, restorative measures, and level of nursing 259 intensity, requires intermediate intensive care through direct 260 observation and monitoring; multiple assessments; specialized 261 interventions; evaluations; and education or teaching of the 262 patient, the patient’s family, or other representatives by a 263 competent and experienced direct care registered nurse. The term 264 includes a unit established to provide care to patients who have 265 moderate or potentially severe physiological instability 266 requiring technical support, but not necessarily artificial life 267 support. As used in this subparagraph, the term: 268 a. “Artificial life support” means a system that uses 269 medical technology to aid, support, or replace a vital function 270 of the body which has been seriously damaged. 271 b. “Technical support” means the use of specialized 272 equipment by a direct care registered nurse in providing for 273 invasive monitoring, telemetry, and mechanical ventilation for 274 the immediate amelioration or remediation of severe pathology 275 for a patient requiring less care than intensive care, but more 276 care than the care provided in a surgical unit. 277 7. “Surgical unit” means a unit established to safeguard 278 and protect a patient whose severity of illness, including all 279 co-occurring morbidities, restorative measures, and level of 280 nursing intensity, requires continuous care through direct 281 observation and monitoring; multiple assessments; specialized 282 interventions; evaluations; and education or teaching of the 283 patient, the patient’s family, or other representatives by a 284 competent and experienced direct care registered nurse. The term 285 includes a unit established to provide care to patients who 286 require less than intensive care or step-down care; patients who 287 receive 24-hour inpatient general medical care or postsurgical 288 care, or both; and mixed populations of patients of diverse 289 diagnoses and diverse ages, excluding pediatric patients. 290 8. “Telemetry unit” means a unit established to safeguard 291 and protect a patient whose severity of illness, including all 292 co-occurring morbidities, restorative measures, and level of 293 nursing intensity, requires intermediate intensive care through 294 direct observation and monitoring; multiple assessments; 295 specialized interventions; evaluations; and education or 296 teaching of the patient, the patient’s family, or other 297 representatives by a competent and experienced direct care 298 registered nurse. The term includes a unit in which specialized 299 equipment is used to provide for the electronic monitoring, 300 recording, retrieval, and display of cardiac electrical signals. 301 (i) “Long-term acute care hospital” means a hospital or 302 health care facility that specializes in providing long-term 303 acute care to medically complex patients. The term includes a 304 freestanding and hospital-within-hospital model of a long-term 305 acute care facility. 306 (j) “Overtime” means the hours worked in excess of: 307 1. An agreed-upon, predetermined, regularly scheduled 308 shift; 309 2. Twelve hours in a 24-hour period; or 310 3. Eighty hours in a 14-day period. 311 (k) “Patient assessment” means the use of critical thinking 312 by a direct care registered nurse, and the intellectually 313 disciplined process of actively and skillfully interpreting, 314 applying, analyzing, synthesizing, or evaluating data obtained 315 through direct observation and communication with others. 316 (l) “Professional judgment” means the intellectual, 317 educated, informed, and experienced process that a direct care 318 registered nurse exercises in forming an opinion and reaching a 319 clinical decision that is in the exclusive interests of the 320 patient and is based upon the analysis of data, information, and 321 scientific evidence. 322 (m) “Skill mix” means the differences in licensing, 323 specialty, and experience among direct care registered nurses. 324 (3) MINIMUM DIRECT CARE REGISTERED NURSE STAFFING LEVEL 325 REQUIREMENTS.— 326 (a) A health care facility shall implement a staffing plan 327 that provides for a minimum direct care registered nurse 328 staffing level in accordance with the general requirements set 329 forth in this subsection and the direct care registered nurse 330 staffing levels in a clinical unit as specified in paragraph 331 (b). Staffing levels for patient care tasks that do not require 332 a direct care registered nurse are not included within these 333 ratios and shall be determined pursuant to an acuity-based 334 patient classification system defined by agency rule. 335 1. A health care facility may not assign a direct care 336 registered nurse to a clinical unit unless the health care 337 facility and the direct care registered nurse determine that 338 such nurse has demonstrated competence in providing care in the 339 clinical unit and has also received orientation in the clinical 340 unit’s area of specialty which is sufficient to provide 341 competent, safe, therapeutic, and effective care to a patient in 342 that unit. The policies and procedures of the health care 343 facility must contain the criteria for making this 344 determination. 345 2. The direct care registered nurse staffing levels 346 represent the maximum number of patients that may be assigned to 347 one direct care registered nurse at any one time. 348 3. A health care facility: 349 a. May not average the total number of patients and the 350 total number of direct care registered nurses assigned to 351 patients in a hospital unit or clinical unit during any period 352 for purposes of meeting the requirements under this subsection. 353 b. May not impose mandatory overtime in order to meet the 354 minimum direct care registered nurse staffing levels in the 355 hospital unit or clinical unit which are required under this 356 subsection. 357 c. Shall ensure that only a direct care registered nurse 358 may relieve another direct care registered nurse during breaks, 359 meals, and routine absences from a hospital unit or clinical 360 unit. 361 d. May not lay off licensed practical nurses, licensed 362 psychiatric technicians, certified nursing assistants, or other 363 ancillary support staff to meet the direct care registered nurse 364 staffing levels required in this subsection for a hospital unit 365 or clinical unit. 366 4. Only a direct care registered nurse may be assigned to 367 an intensive care newborn nursery service unit, which 368 specifically requires a direct care registered nurse staffing 369 level of one such nurse to two or fewer infants at all times. 370 5. In the emergency department, only a direct care 371 registered nurse may be assigned to a triage patient or a 372 critical care patient. 373 a. The direct care registered nurse staffing level for 374 triage patients or critical care patients in the emergency 375 department must be one such nurse to two or fewer patients at 376 all times. 377 b. At least two direct care registered nurses must be 378 physically present in the emergency department when a patient is 379 present. 380 c. Triage, radio, specialty, or flight registered nurses do 381 not count in the calculation of direct care registered nurse 382 staffing levels. Triage registered nurses may not be assigned 383 the responsibility of the base radio. 384 6. Only a direct care registered nurse may be assigned to a 385 labor and delivery unit. 386 a. The direct care registered nurse staffing level must be 387 one such nurse to one active labor patient, or one patient 388 having medical or obstetrical complications, during the 389 initiation of epidural anesthesia and during circulation for a 390 caesarean section delivery. 391 b. The direct care registered nurse staffing level for 392 antepartum patients who are not in active labor must be one such 393 nurse to three or fewer patients at all times. 394 c. In the event of a caesarean delivery, the direct care 395 registered nurse staffing level must be one such nurse to four 396 or fewer mother-plus-infant couplets. 397 d. In the event of multiple births, the direct care 398 registered nurse staffing level must be one such nurse to six or 399 fewer mother-plus-infant couplets. 400 e. The direct care registered nurse staffing level for 401 postpartum areas in which the direct care registered nurse’s 402 assignment consists of only mothers must be one such nurse to 403 four or fewer patients at all times. 404 f. The direct care registered nurse staffing level for 405 postpartum patients or postsurgical gynecological patients must 406 be one such nurse to four or fewer patients at all times. 407 g. The direct care registered nurse staffing level for the 408 well-baby nursery unit must be one such nurse to five or fewer 409 patients at all times. 410 h. The direct care registered nurse staffing level for 411 unstable newborns and newborns in the resuscitation period as 412 assessed by a direct care registered nurse must be at least one 413 such nurse to one patient at all times. 414 i. The direct care registered nurse staffing level for 415 newborns must be one such nurse to four or fewer patients at all 416 times. 417 7. The direct care registered nurse staffing level for 418 patients receiving conscious sedation must be at least one such 419 nurse to one patient at all times. 420 (b) A health care facility’s staffing plan must provide 421 that, at all times during each shift within a unit of the 422 facility, a direct care registered nurse is assigned to not more 423 than: 424 1. One patient in a trauma emergency unit; 425 2. One patient in an operating room unit. The operating 426 room must have at least one direct care registered nurse 427 assigned to the duties of the circulating registered nurse and a 428 minimum of one additional person as a scrub assistant for each 429 patient-occupied operating room; 430 3. Two patients in a critical care unit, including neonatal 431 intensive care units; emergency critical care and intensive care 432 units; labor and delivery units; coronary care units; acute 433 respiratory care units; postanesthesia units, regardless of the 434 type of anesthesia administered; and postpartum units, so that 435 the direct care registered nurse staffing level is one such 436 nurse to two or fewer patients at all times; 437 4. Three patients in an emergency room unit; step-down unit 438 or intermediate intensive care unit; pediatric unit; telemetry 439 unit; or combined labor and postpartum unit so that the direct 440 care registered nurse staffing level is one such nurse to three 441 or fewer patients at all times; 442 5. Four patients in a surgical unit, antepartum unit, 443 intermediate care nursery unit, psychiatric unit, or presurgical 444 or other specialty care unit so that the direct care registered 445 nurse staffing level is one such nurse to four or fewer patients 446 at all times; 447 6. Five patients in a rehabilitation unit or skilled 448 nursing unit so that the direct care registered nurse staffing 449 level is one such nurse to five or fewer patients at all times; 450 7. Six patients in a well-baby nursery unit so that the 451 direct care registered nurse staffing level is one such nurse to 452 six or fewer patients at all times; or 453 8. Three mother-plus-infant couplets in a postpartum unit 454 so that the direct care registered nurse staffing level is one 455 such nurse to three or fewer mother-plus-infant couplets at all 456 times. 457 (c)1. Identifying a hospital unit or clinical unit by a 458 name or term other than those defined in subsection (2) does not 459 affect the requirement of direct care registered nurse staffing 460 levels identified for the level of intensity or type of care 461 described in paragraphs (a) and (b). 462 2. Patients shall be cared for only in hospital units or 463 clinical units in which the level of intensity, type of care, 464 and direct care registered nurse staffing levels meet the 465 individual requirements and needs of each patient. A health care 466 facility may not use an acuity-adjustable unit to care for a 467 patient. 468 3. A health care facility may not use a video camera or 469 monitor or any form of electronic visualization of a patient to 470 substitute for the direct observation required for patient 471 assessment by the direct care registered nurse and for patient 472 protection provided by an attendant. 473 (d) The requirements established under this subsection do 474 not apply during a declared state of emergency, as defined in 475 subsection (2), if a health care facility is requested or 476 expected to provide an exceptional level of emergency or other 477 medical services. 478 (e) The chief nursing officer or his or her designee shall 479 develop a staffing plan for each hospital unit or clinical unit. 480 1. The staffing plan must be in writing and, based on 481 individual patient care needs determined by the acuity-based 482 patient classification system, must specify individual patient 483 care requirements and the staffing levels for direct care 484 registered nurses and other licensed and unlicensed personnel. 485 The direct care registered nurse staffing level on any shift may 486 not fall below the requirements in paragraphs (a) and (b) at any 487 time. 488 2. In addition to the requirements of direct care 489 registered nurse staffing levels in paragraphs (a) and (b), each 490 health care facility shall assign additional nursing staff, 491 including, but not limited to, licensed practical nurses, 492 licensed psychiatric technicians, and certified nursing 493 assistants, through the implementation of a valid acuity-based 494 patient classification system for determining nursing care needs 495 of individual patients which reflects the assessment of patient 496 nursing care requirements made by the assigned direct care 497 registered nurse and which provides for shift-by-shift staffing 498 based on those requirements. The direct care registered nurse 499 staffing levels specified in paragraphs (a) and (b) constitute 500 the minimum number of direct care registered nurses who shall be 501 assigned to provide direct patient care. 502 3. In developing the staffing plan, a health care facility 503 shall provide for direct care registered nurse staffing levels 504 that are above the minimum levels required in paragraphs (a) and 505 (b) based upon consideration of the following factors: 506 a. The number of patients and their acuity levels as 507 determined by the application of a patient classification system 508 on a shift-by-shift basis. 509 b. The anticipated admissions, discharges, and transfers of 510 patients during each shift which affect direct patient care. 511 c. The specialized experience required of direct care 512 registered nurses on a particular hospital unit or clinical 513 unit. 514 d. Staffing levels of other health care personnel who 515 provide direct patient care services for patients who normally 516 do not require care by a direct care registered nurse. 517 e. The level of efficacy of technology that is available 518 that affects the delivery of direct patient care. 519 f. The level of familiarity with hospital practices, 520 policies, and procedures by a direct care registered nurse from 521 a temporary agency during a shift. 522 g. Obstacles to efficiency in the delivery of patient care 523 caused by the physical layout of the health care facility. 524 4. A health care facility shall specify the acuity-based 525 patient classification system used to document actual staffing 526 in each unit for each shift. 527 5. A health care facility shall annually evaluate: 528 a. The reliability of the acuity-based patient 529 classification system for validating staffing requirements to 530 determine whether such system accurately measures individual 531 patient care needs and accurately predicts the staffing 532 requirements for direct care registered nurses, licensed 533 practical nurses, licensed psychiatric technicians, and 534 certified nursing assistants, based exclusively on individual 535 patient needs. 536 b. The validity of the acuity-based patient classification 537 system. 538 6. A health care facility shall annually update its 539 staffing plan and acuity-based patient classification system to 540 the extent appropriate based on the annual evaluation conducted 541 under subparagraph 5. If the evaluation reveals that adjustments 542 are necessary to ensure accuracy in measuring patient care 543 needs, such adjustments must be implemented within 30 days after 544 such determination. 545 7. Any acuity-based patient classification system adopted 546 by a health care facility under this subsection must be 547 transparent in all respects, including disclosure of detailed 548 documentation of the methodology used to predict nurse staffing; 549 an identification of each factor, assumption, and value used in 550 applying such methodology; an explanation of the scientific and 551 empirical basis for each such assumption and value; and 552 certification by a knowledgeable and authorized representative 553 of the health care facility that the disclosures regarding 554 methods used for testing and validating the accuracy and 555 reliability of such system are true and complete. 556 a. The documentation required by this subparagraph shall be 557 submitted in its entirety to the agency as a mandatory condition 558 of licensure, with a certification by the chief nursing officer 559 of the health care facility that the documentation completely 560 and accurately reflects implementation of a valid acuity-based 561 patient classification system used to determine nurse staffing 562 by the facility for each shift in each hospital unit or clinical 563 unit in which patients receive care. The chief nursing officer 564 shall execute the certification under penalty of perjury, and 565 the certification must contain an expressed acknowledgment that 566 any false statement constitutes fraud and is subject to criminal 567 and civil prosecution and penalties. 568 b. Such documentation must be available for public 569 inspection in its entirety in accordance with procedures 570 established by administrative rules adopted by the agency, 571 consistent with the purposes of this section. 572 8. A staffing plan of a health care facility shall be 573 developed and evaluated by a committee created by the health 574 care facility. At least half of the members of the committee 575 must be unit-specific competent direct care registered nurses. 576 a. The chief nursing officer at the facility shall appoint 577 the members who are not direct care registered nurses. The 578 direct care registered nurses on the committee shall be 579 appointed by the chief nursing officer if the direct care 580 registered nurses are not represented by a collective bargaining 581 agreement or by an authorized collective bargaining agent. 582 b. In case of a dispute, the direct care registered nurse 583 assessment shall prevail. 584 c. This section does not authorize conduct that is 585 prohibited under the National Labor Relations Act or the Federal 586 Labor Relations Act of 1978. 587 9. By July 1, 2021, the agency shall approve uniform 588 statewide standards for a standardized acuity tool for use in 589 health care facilities. The standardized acuity tool must 590 provide a method for establishing direct care registered nurse 591 staffing requirements that exceed the required direct care 592 registered nurse staffing levels in the hospital units or 593 clinical units in paragraphs (a) and (b). 594 a. The proposed standards shall be developed by a committee 595 created by the health care facility consisting of up to 20 596 members. At least 11 of the committee members must be registered 597 nurses who are currently licensed and employed as direct care 598 registered nurses, and the remaining committee members must 599 include a sufficient number of technical or scientific experts 600 in specialized fields who are involved in the design and 601 development of an acuity-based patient classification system 602 that meets the requirements of this section. 603 b. A person who has any employment or any commercial, 604 proprietary, financial, or other personal interest in the 605 development, marketing, or use of a private patient 606 classification system product or related methodology, 607 technology, or component system is not eligible to serve on the 608 committee. A candidate for appointment to the committee may not 609 be confirmed as a member until the candidate files a disclosure 610 of-interest statement with the agency, along with a signed 611 certification of full disclosure and complete accuracy under 612 oath, which provides all necessary information as determined by 613 the agency to demonstrate the absence of actual or potential 614 conflict of interest. All such filings are subject to public 615 inspection. 616 c. Within 1 year after the official commencement of 617 committee operations, the committee shall provide a written 618 report to the agency which proposes uniform standards for a 619 valid, acuity-based patient classification system, along with a 620 sufficient explanation and justification to allow for competent 621 review and determination of sufficiency by the agency. The 622 agency shall disclose the report to the public upon notice of 623 public hearings and provide a public comment period for proposed 624 adoption of uniform standards for an acuity-based patient 625 classification system by the agency. 626 10. A hospital shall adopt and implement the acuity-based 627 patient classification system and provide staffing based on the 628 standardized acuity tool. Any additional direct care registered 629 nurse staffing level that exceeds the direct care registered 630 nurse staffing levels described in paragraphs (a) and (b) shall 631 be assigned in a manner determined by such standardized acuity 632 tool. 633 11. A health care facility shall submit to the agency its 634 annually updated staffing plan and acuity-based patient 635 classification system as required under this paragraph. 636 (f)1. In each hospital unit or clinical unit, a health care 637 facility shall post a notice in a form specified by agency rule 638 which: 639 a. Explains the requirements imposed under this subsection; 640 b. Includes actual direct care registered nurse staffing 641 levels during each shift at the hospital unit or clinical unit; 642 c. Is visible, conspicuous, and accessible to staff and 643 patients of the hospital unit or clinical unit and the public; 644 d. Identifies staffing requirements as determined by the 645 acuity-based patient classification system for each hospital 646 unit or clinical unit, documented and posted in the unit for 647 public view on a day-to-day, shift-by-shift basis; 648 e. Documents the actual number of staff and the skill mix 649 of such staff in each hospital unit or clinical unit, documented 650 and posted in the unit for public view on a day-to-day, shift 651 by-shift basis; and 652 f. Reports the variance between the required and actual 653 staffing patterns in each hospital unit or clinical unit, 654 documented and posted in the unit for public view on a day-to 655 day, shift-by-shift basis. 656 2.a. A long-term acute care hospital shall maintain 657 accurate records of actual staffing levels in each hospital unit 658 or clinical unit for each shift for at least 2 years. Such 659 records must include: 660 (I) The number of patients in each unit; 661 (II) The identity and duty hours of each direct care 662 registered nurse, licensed practical nurse, licensed psychiatric 663 technician, and certified nursing assistant assigned to each 664 patient in the hospital unit or clinical unit for each shift; 665 and 666 (III) A copy of each posted notice. 667 b. A health care facility shall make its staffing plan and 668 acuity-based patient classification system required under 669 paragraph (e), and all documentation related to such plan and 670 system, available to the agency; to direct care registered 671 nurses and their collective bargaining representatives, if any; 672 and to the public under rules adopted by the agency. 673 3. The agency shall conduct periodic audits to ensure 674 implementation of the staffing plan in accordance with this 675 subsection and to ensure the accuracy of the staffing plan and 676 the acuity-based patient classification system required under 677 paragraph (e). 678 (g) A health care facility shall plan for routine 679 fluctuations such as admissions, discharges, and transfers in 680 the patient census. If a declared state of emergency causes a 681 change in the number of patients in a unit, the health care 682 facility must demonstrate that immediate and diligent efforts 683 are made to maintain required staffing levels. 684 (h) The following activities are prohibited: 685 1. The direct assignment of unlicensed personnel by a 686 health care facility to perform functions required of a direct 687 care registered nurse in lieu of care being delivered by a 688 licensed or registered nurse under the clinical supervision of a 689 direct care registered nurse. 690 2. The performance of patient care tasks by unlicensed 691 personnel which require the clinical assessment, judgment, and 692 skill of a licensed or registered nurse, including, but not 693 limited to: 694 a. Nursing activities that require nursing assessment and 695 judgment during implementation; 696 b. Physical, psychological, or social assessments that 697 require nursing judgment, intervention, referral, or followup; 698 and 699 c. Formulation of a plan of nursing care and evaluation of 700 a patient’s response to the care provided, including 701 administration of medication; venipuncture or intravenous 702 therapy; parenteral or tube feedings; invasive procedures, 703 including inserting nasogastric tubes, inserting catheters, or 704 tracheal suctioning; and educating a patient and the patient’s 705 family concerning the patient’s health care problems, including 706 postdischarge care. However, a phlebotomist, emergency room 707 technician, or medical technician may, under the general 708 supervision of the clinical laboratory director, or his or her 709 designee, or a physician, perform venipunctures in accordance 710 with written hospital policies and procedures. 711 (4) PROFESSIONAL PRACTICE STANDARDS FOR DIRECT CARE 712 REGISTERED NURSES WORKING IN A HEALTH CARE FACILITY.— 713 (a) A direct care registered nurse employing scientific 714 knowledge and experience in the physical, social, and biological 715 sciences, and exercising independent judgment in applying the 716 nursing process, shall directly provide: 717 1. Continuous and ongoing assessments of the patient’s 718 condition. 719 2. The planning, clinical supervision, implementation, and 720 evaluation of the nursing care provided to each patient. 721 3. The assessment, planning, implementation, and evaluation 722 of patient education, including the ongoing postdischarge 723 education of each patient. 724 4. The delivery of patient care, which must reflect all 725 elements of the nursing process and must include assessment, 726 nursing diagnosis, planning, intervention, evaluation, and, as 727 circumstances require, patient advocacy, and shall be initiated 728 by a direct care registered nurse at the time of admission. 729 5. The nursing plan for the patient care, which shall be 730 discussed with and developed as a result of coordination with 731 the patient, the patient’s family or other representatives, when 732 appropriate, and the staff of other disciplines involved in the 733 care of the patient. 734 6. An evaluation of the effectiveness of the care plan 735 through assessments based on direct observation of the patient’s 736 physical condition and behavior, signs and symptoms of illness, 737 and reactions to treatment, and through communication with the 738 patient and the health care team members, and modification of 739 the plan as needed. 740 7. Information related to the initial assessment and 741 reassessments of the patient, nursing diagnosis, plan, 742 intervention, evaluation, and patient advocacy, which shall be 743 permanently recorded in the patient’s medical record as 744 narrative direct care progress notes. The practice of charting 745 by exception is prohibited. 746 (b)1. A patient assessment requires direct observation of 747 the patient’s signs and symptoms of illness, reaction to 748 treatment, behavior and physical condition, and interpretation 749 of information obtained from the patient and others, including 750 the health care team members. A patient assessment requires data 751 collection by a direct care registered nurse and the analysis, 752 synthesis, and evaluation of such data. 753 2. Only a direct care registered nurse may perform a 754 patient assessment. A licensed practical nurse or licensed 755 psychiatric technician may assist a direct care registered nurse 756 in data collection. 757 (c)1. A direct care registered nurse shall determine the 758 nursing care needs of individual patients through the process of 759 ongoing patient assessments, nursing diagnosis, formulation, and 760 adjustment of nursing care plans. 761 2. The prediction of individual patient nursing care needs 762 for prospective assignment of direct care registered nurses 763 shall be based on individual patient assessments of the direct 764 care registered nurse assigned to each patient and in accordance 765 with a documented acuity-based patient classification system as 766 required in subsection (3). 767 (d) Competent performance of the essential functions of a 768 direct care registered nurse as provided in this section 769 requires the exercise of independent judgment in the exclusive 770 interests of the patient. A direct care registered nurse’s 771 independent judgment while performing the functions described in 772 this section shall be provided in the exclusive interests of the 773 patient and may not, for any purpose, be considered, relied 774 upon, or represented as a job function, authority, 775 responsibility, or activity undertaken in any respect for the 776 purpose of serving the business, commercial, operational, or 777 other institutional interests of the health care facility 778 employer. 779 (e)1. In addition to the prohibition on assignments of 780 patient care tasks provided in paragraph (3)(h), a direct care 781 registered nurse may not assign tasks required to implement 782 nursing care for a patient to other licensed nursing staff or to 783 unlicensed staff unless the assigning direct care registered 784 nurse: 785 a. Determines that the personnel assigned the nursing care 786 tasks possess the necessary training, experience, and capability 787 to competently and safely perform such tasks; and 788 b. Effectively supervises the clinical functions and 789 nursing care tasks performed by the assigned personnel. 790 2. The exercise of clinical supervision of nursing care 791 personnel by a direct care registered nurse in the performance 792 of the functions as provided in this subsection must be in the 793 exclusive interests of the patient and may not, for any purpose, 794 be considered, relied upon, or represented as a job function, 795 authority, responsibility, or activity undertaken in any respect 796 for the purpose of serving the business, commercial, 797 operational, or other institutional interests of the health care 798 facility employer, but constitutes the exercise of professional 799 nursing authority and duty in the exclusive interests of the 800 patient. 801 (f) A health care facility may not deploy technology that 802 limits the direct care provided by a direct care registered 803 nurse in the performance of functions that are part of the 804 nursing process, including the full exercise of independent 805 professional judgment in the assessment, planning, 806 implementation, and evaluation of care, or that limits a direct 807 care registered nurse from acting as a patient advocate in the 808 exclusive interests of the patient. Technology may not be skill 809 degrading, interfere with the direct care registered nurse’s 810 provision of individualized patient care, or override the direct 811 care registered nurse’s independent professional judgment. 812 (g) This subsection applies only to direct care registered 813 nurses employed by or providing care in a health care facility. 814 (5) DIRECT CARE REGISTERED NURSE’S DUTY AND RIGHT OF 815 PATIENT ADVOCACY.— 816 (a) A direct care registered nurse has a duty and right to 817 act and provide care in the exclusive interests of the patient 818 and to act as the patient’s advocate. 819 (b) A direct care registered nurse shall always provide 820 competent, safe, therapeutic, and effective nursing care to an 821 assigned patient. 822 1. Before accepting a patient assignment, a direct care 823 registered nurse must have the necessary knowledge, judgment, 824 skills, and ability to provide the required care. It is the 825 responsibility of the direct care registered nurse to determine 826 whether he or she is clinically competent to perform the nursing 827 care required by a patient who is in a particular clinical unit 828 or who has a particular diagnosis, condition, prognosis, or 829 other determinative characteristic of nursing care, and whether 830 acceptance of a patient assignment would expose the patient to 831 the risk of harm. 832 2. If the direct care registered nurse is not competent to 833 perform the care required for a patient assigned for nursing 834 care or if the assignment would expose the patient to risk of 835 harm, the direct care registered nurse may not accept the 836 patient care assignment. Such refusal to accept a patient care 837 assignment is an exercise of the direct care registered nurse’s 838 duty and right of patient advocacy. 839 (c) A direct care registered nurse may refuse to accept an 840 assignment as a nurse in a health care facility if: 841 1. The assignment would violate chapter 464 or rules 842 adopted thereunder; 843 2. The assignment would violate subsection (3), subsection 844 (4), or this subsection; or 845 3. The direct care registered nurse is not prepared by 846 education, training, or experience to fulfill the assignment 847 without compromising the safety of a patient or jeopardizing the 848 license of the direct care registered nurse. 849 (d) A direct care registered nurse may refuse to perform an 850 assigned task as a nurse in a health care facility if: 851 1. The assigned task would violate chapter 464 or rules 852 adopted thereunder; 853 2. The assigned task is outside the scope of practice of 854 the direct care registered nurse; or 855 3. The direct care registered nurse is not prepared by 856 education, training, or experience to fulfill the assigned task 857 without compromising the safety of a patient or jeopardizing the 858 license of the direct care registered nurse. 859 (e) In the course of performing the responsibilities and 860 essential functions described in subsection (4), the direct care 861 registered nurse assigned to a patient shall receive orders 862 initiated by physicians and other legally authorized health care 863 professionals within their scope of licensure regarding patient 864 care services to be provided to the patient, including, but not 865 limited to, the administration of medications and therapeutic 866 agents that are necessary to implement a treatment, a 867 rehabilitative regimen, or disease prevention. 868 1. The direct care registered nurse shall assess each such 869 order before implementation to determine if the order is: 870 a. In the exclusive interests of the patient; 871 b. Initiated by a person legally authorized to issue the 872 order; and 873 c. Issued in accordance with the applicable laws and rules 874 governing nursing care. 875 2. If the direct care registered nurse determines that the 876 criteria provided in subparagraph 1. have not been satisfied 877 with respect to a particular order or if the direct care 878 registered nurse has some doubt regarding the meaning or 879 conformance of the order with such criteria, he or she shall 880 seek clarification from the initiator of the order, the 881 patient’s physician, or another appropriate medical officer 882 before implementing the order. 883 3. If, upon clarification, the direct care registered nurse 884 determines that the criteria for implementation of an order 885 provided in subparagraph 1. have not been satisfied, the direct 886 care registered nurse may refuse implementation on the basis 887 that the order is not in the exclusive interests of the patient. 888 Seeking clarification of an order or refusing an order as 889 described in this subparagraph is an exercise of the direct care 890 registered nurse’s duty and right of patient advocacy. 891 (f) A direct care registered nurse shall, as circumstances 892 require, initiate action to improve the patient’s health care or 893 to change a decision or activity that, in the professional 894 judgment of the direct care registered nurse, is against the 895 exclusive interests or desires of the patient or shall give the 896 patient the opportunity to make informed decisions about the 897 health care before it is provided. 898 (6) FREE SPEECH; PATIENT PROTECTION.— 899 (a) A health care facility may not: 900 1. Discharge, discriminate against, or retaliate against in 901 any manner with respect to any aspect of employment, including 902 discharge, promotion, compensation, or terms, conditions, or 903 privileges of employment, a direct care registered nurse based 904 on the direct care registered nurse’s refusal to accept an 905 assignment pursuant to paragraph (5)(c) or an assigned task 906 pursuant to paragraph (5)(d). 907 2. File a complaint or a report against a direct care 908 registered nurse with the Board of Nursing or the agency because 909 of the direct care registered nurse’s refusal of an assignment 910 pursuant to paragraph (5)(c) or an assigned task pursuant to 911 paragraph (5)(d). 912 (b) A direct care registered nurse who has been discharged, 913 discriminated against, or retaliated against in violation of 914 subparagraph (a)1. or against whom a complaint or a report has 915 been filed in violation of subparagraph (a)2. may bring a cause 916 of action in a court of competent jurisdiction. A direct care 917 registered nurse who prevails in the cause of action is entitled 918 to one or more of the following: 919 1. Reinstatement. 920 2. Reimbursement of lost wages, compensation, and benefits. 921 3. Attorney fees. 922 4. Court costs. 923 5. Other damages. 924 (c) A direct care registered nurse, a patient, or any other 925 individual may file a complaint with the agency against a health 926 care facility that violates this section. For any complaint 927 filed, the agency shall: 928 1. Receive and investigate the complaint; 929 2. Determine whether a violation of this section as alleged 930 in the complaint has occurred; and 931 3. If such a violation has occurred, issue an order 932 prohibiting the health care facility from subjecting the 933 complaining direct care registered nurse, the patient, or the 934 other individual to any retaliation described in paragraph (a). 935 (d)1. A health care facility may not discriminate or 936 retaliate in any manner against any patient, employee, or 937 contract employee of the facility, or any other individual, on 938 the basis that such individual, in good faith, individually or 939 in conjunction with another person or persons, has presented a 940 grievance or complaint; initiated or cooperated in an 941 investigation or proceeding by a governmental entity, regulatory 942 agency, or private accreditation body; made a civil claim or 943 demand; or filed an action relating to the care, services, or 944 conditions of the health care facility or of any affiliated or 945 related facilities. 946 2. For purposes of this paragraph, an individual is deemed 947 to be acting in good faith if the individual reasonably believes 948 that the information reported or disclosed is true. 949 (e)1. A health care facility may not: 950 a. Interfere with, restrain, or deny the exercise of, or 951 the attempt to exercise, any right provided or protected under 952 this section; or 953 b. Coerce or intimidate any person regarding the exercise 954 of, or the attempt to exercise, such right. 955 2. A health care facility may not discriminate or retaliate 956 against any person for opposing any facility policy, practice, 957 or action that is alleged to violate, breach, or fail to comply 958 with this section. 959 3. A health care facility, or an individual representing a 960 health care facility, may not make, adopt, or enforce any rule, 961 regulation, policy, or practice that in any manner directly or 962 indirectly prohibits, impedes, or discourages a direct care 963 registered nurse from engaging in free speech or disclosing 964 information as provided under this section. 965 4. A health care facility, or an individual representing a 966 health care facility, may not in any way interfere with the 967 rights of direct care registered nurses to organize, bargain 968 collectively, and engage in concerted activity under s. 7 of the 969 National Labor Relations Act. 970 5. A health care facility shall post in an appropriate 971 location in each hospital unit or clinical unit a notice in a 972 form specified by the agency which: 973 a. Explains the rights of nurses, patients, and other 974 individuals under this subsection; 975 b. Includes a statement that a nurse, patient, or other 976 individual may file a complaint with the agency against a health 977 care facility that violates this subsection; and 978 c. Provides instructions on how to file a complaint. 979 (f)1. The agency shall establish a toll-free telephone 980 hotline to provide information regarding the requirements of 981 this section and to receive reports of violations of this 982 section. 983 2. A health care facility shall provide each patient 984 admitted to the facility for inpatient care with the toll-free 985 telephone hotline described in subparagraph 1. and shall give 986 notice to each patient that the hotline may be used to report 987 inadequate staffing or care. 988 (7) ENFORCEMENT.— 989 (a) In addition to any other penalty prescribed by law, the 990 agency may impose civil penalties as follows: 991 1. Against a health care facility that violates this 992 section, a civil penalty of up to $25,000 for each violation, 993 except that the agency shall impose a civil penalty of at least 994 $25,000 for each violation if the agency determines that the 995 health care facility has a pattern of such violation. 996 2. Against an individual who is employed by a health care 997 facility who violates this section, a civil penalty of up to 998 $20,000 for each violation. 999 (b) The agency shall post on its website the names of 1000 health care facilities against which civil penalties have been 1001 imposed under this subsection and such additional information as 1002 the agency deems necessary. 1003 Section 3. This act shall take effect July 1, 2020.