HB 633

1	A bill to be entitled
2	An act relating to the staffing of health care facilities;
3	creating ss. 395.051-395.057, F.S.; creating the Safe
4	Staffing for Quality Care Act; providing legislative
5	findings; defining terms; prescribing safe staffing
6	standards for health care facilities; requiring licensed
7	facilities to submit an annual staffing plan to the Agency
8	for Health Care Administration; providing standards for
9	the required skill mix; requiring compliance with the
10	staffing plan; requiring recordkeeping; prohibiting
11	mandatory overtime; providing applicability; providing to
12	employees the right to refuse certain assignments and the
13	right to report suspected violations of safe staffing
14	standards; providing for the agency to enforce compliance
15	with the act; requiring the agency to develop rules;
16	providing an effective date.
17
18	Be It Enacted by the Legislature of the State of Florida:
19
20	Section 1.  Section 395.051, Florida Statutes, is created
21	to read:
22	395.051  Short title.--Sections 395.051-395.057 may be
23	cited as the "Safe Staffing for Quality Care Act."
24	Section 2.  Section 395.052, Florida Statutes, is created
25	to read:
26	395.052  Legislative findings.--The Legislature finds that:
27	(1)  The state has a substantial interest in ensuring that
28	delivery of health care services to patients in health care
29	facilities located in this state is adequate and safe and that
30	health care facilities retain sufficient nursing staff so as to
31	promote optimal health care outcomes.
32	(2)  Recent changes in our health care delivery system are
33	resulting in a higher acuity level among patients in health care
34	facilities.
35	(3)  Registered nurses constitute the highest percentage of
36	direct health care staff in acute care facilities and have a
37	central role in delivering health care.
38	(4)  Extensive research indicates that inadequate
39	registered nurse staffing in hospitals can result in increased
40	patient death rates, dangerous medical errors, and increased
41	length of stay.
42	(5)  To ensure adequate protection and care for patients in
43	health care facilities, it is essential that qualified
44	registered nurses who are trained and authorized to deliver
45	nursing services be accessible and available to meet the nursing
46	needs of patients.
47	Section 3.  Section 395.053, Florida Statutes, is created
48	to read:
49	395.053  Definitions.--As used in this act, the term:
50	(1)  "Acuity system" means an established measurement
51	instrument that:
52	(a)  Predicts nursing care requirements for individual
53	patients based on the severity of patient illness, the need for
54	specialized equipment and technology, the intensity of nursing
55	interventions required, and the complexity of clinical nursing
56	judgment needed to design, implement, and evaluate the patient's
57	nursing care plan;
58	(b)  Details the amount of nursing care needed, both in the
59	number of registered nurses and in the skill mix of nursing
60	personnel required daily for each patient in a nursing
61	department or unit; and
62	(c)  Is stated in terms that can be readily used and
63	understood by direct-care nursing staff.
64	(2)  "Assessment tool" means a measurement system that
65	compares the staffing level in each nursing department or unit
66	against actual patient nursing care requirements in order to
67	review the accuracy of an acuity system.
68	(3)  "Declared state of emergency" means an officially
69	designated state of emergency which has been declared by a
70	federal, state, or local government official who has the
71	authority to declare that the state, county, municipality, or
72	locality is in a state of emergency. The term does not include a
73	state of emergency which results from a labor dispute in the
74	health care industry.
75	(4)  "Direct-care nurse" or "direct-care nursing staff"
76	means any registered nurse who has direct responsibility to
77	oversee or carry out medical regimens or nursing care for one or
78	more patients. A nurse administrator, nurse supervisor, nurse
79	educator, charge nurse, or other registered nurse who does not
80	have a specific patient assignment may not be included in the
81	calculation of the registered nurse-to-patient ratio.
82	(5)  "Documented staffing plan" means a detailed written
83	plan that sets forth the minimum number, skill mix, and
84	classification of licensed nurses required in each nursing
85	department or unit in the health care facility for a given year,
86	based on reasonable projections derived from the patient census
87	and average acuity level within each department or unit during
88	the previous year, the department or unit size and geography,
89	the nature of services provided, and any foreseeable changes in
90	department or unit size or function during the current year.
91	(6)  "Health care facility" means an acute care hospital;
92	an emergency care, ambulatory, or outpatient surgery facility
93	licensed under s. 395.003; or a psychiatric facility licensed
94	under chapter 394.
95	(7)  "Nurse" means a registered nurse.
96	(8)  "Nursing care" means care that falls within the scope
97	of practice set forth in chapter 464 and other laws and rules or
98	care that is otherwise encompassed within recognized
99	professional standards of nursing practice, including
100	assessment, nursing diagnosis, planning, intervention,
101	evaluation, and patient advocacy.
102	(9)  "On-call time" means time spent by an employee who:
103	(a)  Is not working on the premises of the place of
104	employment but who is compensated for availability; or
105	(b)  As a condition of employment, has agreed to be
106	available to return to the premises of the place of employment
107	on short notice if the need arises.
108	(10)  "Overtime" means the hours worked in excess of any of
109	the following:
110	(a)  An agreed-upon, predetermined, regularly scheduled
111	shift;
112	(b)  Twelve hours in a 24-hour period; or
113	(c)  Eighty hours in a consecutive 14-day period.
114	(11)  "Reasonable efforts," in reference to the prohibition
115	on mandatory overtime, means that the employer is unable to
116	obtain staff coverage even though the employer has:
117	(a)  Sought, from among all available qualified staff who
118	are working, individuals who would volunteer to work extra time;
119	(b)  Contacted employees who have made themselves available
120	to work extra time;
121	(c)  Sought the use of per diem staff; and
122	(d)  Sought personnel from a contracted temporary agency if
123	such staffing is permitted by law or an applicable collective
124	bargaining agreement.
125	(12)  "Skill mix" means the differences in licensing,
126	specialty, and experience among direct-care nurses.
127	(13)  "Staffing level" means the actual numerical
128	registered nurse-to-patient ratio within a nursing department or
129	unit.
130	(14)  "Unforeseeable emergent circumstance" means:
131	(a)  An unforeseen declared national, state, or municipal
132	emergency;
133	(b)  A situation in which a health care disaster plan is
134	activated; or
135	(c)  An unforeseen disaster or other catastrophic event
136	that substantially affects or increases the need for health care
137	services.
138	Section 4.  Section 395.054, Florida Statutes, is created
139	to read:
140	395.054  Facility staffing standards.--
141	(1)  STAFFING PRINCIPLES.--The basic principles of staffing
142	in health care facilities should be focused on patient health
143	care needs and based on consideration of patient acuity levels
144	and services that need to be provided to ensure optimal
145	outcomes. Safe staffing practices recognize the importance of
146	all health care workers in providing quality patient care. The
147	setting of staffing standards for registered nurses is not to be
148	interpreted as justifying the understaffing of other critical
149	health care workers, including licensed practical nurses, social
150	workers, and other licensed or unlicensed assistive personnel.
151	Indeed, the availability of these other health care workers
152	enables registered nurses to focus on the nursing care functions
153	that only registered nurses, by law, are permitted to perform
154	and thereby helps to ensure adequate staffing levels.
155	(2)  SPECIFIC STANDARDS.--Health care facilities shall
156	provide staffing by registered nurses in accordance with the
157	minimum nurse-to-patient ratios that are set forth in this
158	subsection. Staffing for care that does not require a registered
159	nurse is not included within these ratios and must be determined
160	pursuant to the patient classification system. Nurse-to-patient
161	ratios represent the maximum number of patients which are
162	assigned to one registered nurse during one shift. Only nurses
163	providing direct patient care shall be included in the ratios.
164	Nurse administrators, nurse supervisors, charge nurses, and
165	other licensed nurses that do not have a specific patient care
166	assignment may not be included in the calculation of the nurse-
167	to-patient ratio. This section does not prohibit a registered
168	nurse from providing care within the scope of his or her
169	practice to a patient assigned to another nurse.
170	(a)  No more than two patients may be assigned to each
171	registered nurse, so that the minimum registered nurse-to-
172	patient ratio in a critical care unit is 1 to 2 or fewer at any
173	time. As used in this paragraph, the term "critical care unit"
174	means a nursing unit of a general acute care hospital which
175	provides one of the following services: an intensive care
176	service, a postanesthesia recovery service, a burn center
177	service, a coronary care service, or an acute respiratory
178	service. In the intensive care newborn nursery service, no more
179	than two patients may be assigned to each nurse.
180	(b)  In the surgical service operating room, no more than
181	one patient-occupied operating room may be assigned to each
182	registered nurse.
183	(c)  No more than two patients may be assigned to each
184	registered nurse in a labor/delivery unit of the perinatal
185	service, so that the registered nurse-to-patient ratio is 1 to 2
186	or fewer at any time.
187	(d)  No more than three mother-baby couplets may be
188	assigned to each registered nurse in a postpartum area of the
189	perinatal unit at any time. If multiple births have occurred,
190	the total number of mothers plus infants which are assigned to a
191	single registered nurse may not exceed six.
192	(e)  In a hospital that provides basic emergency medical
193	services or comprehensive emergency medical services, no more
194	than three patients who are receiving emergency services may be
195	assigned to each registered nurse, so that the registered nurse-
196	to-patient ratio in an emergency department is 1 to 3 or fewer
197	at any time patients are receiving treatment. No fewer than two
198	registered nurses must be physically present in the emergency
199	department when a patient is present.
200	(f)  The nurse assigned to triage patients may not have a
201	patient assignment, may not be assigned the responsibility for
202	the base ratio, and may not be counted in the registered nurse-
203	to-patient ratio.
204	(g)  When nursing staff are attending critical care
205	patients in the emergency department, no more than two patients
206	may be assigned to each registered nurse. When nursing staff in
207	the emergency department are attending trauma patients, no more
208	than one patient may be assigned to each registered nurse at any
209	time.
210	(h)  No more than three patients may be assigned to each
211	registered nurse in a step-down unit, so that the minimum
212	registered nurse-to-patient ratio in a step-down unit is 1 to 3
213	or fewer at any time. As used in this paragraph, the term:
214	1.  "Artificial life support" means a system that uses
215	medical technology to aid, support, or replace a vital function
216	of the body which has been seriously damaged.
217	2.  "Step-down unit" means a unit that is organized,
218	operated, and maintained to provide for the monitoring and care
219	of patients who have moderate or potentially severe physiologic
220	instability that requires technical support but not necessarily
221	artificial life support.
222	3.  "Technical support" means specialized equipment or
223	personnel, or both, that provides for invasive monitoring,
224	telemetry, and mechanical ventilation, for the immediate
225	amelioration or remediation of severe pathology for those
226	patients who require less care than intensive care but more than
227	that which is available from medical/surgical care.
228	(i)  No more than three patients may be assigned to each
229	registered nurse, so that the minimum registered nurse-to-
230	patient ratio in a telemetry unit is 1 to 3 or fewer at any
231	time. As used in this paragraph, the term "telemetry unit" means
232	a unit designated for the electronic monitoring, recording,
233	retrieval, and display of cardiac electrical signals.
234	(j)  No more than four patients may be assigned to each
235	registered nurse, so that the minimum registered nurse-to-
236	patient ratio in medical/surgical care units is 1 to 4 or fewer
237	at any time. As used in this paragraph, the term
238	"medical/surgical unit" means a unit that has beds classified as
239	medical/surgical in which patients who require less care than
240	that which is available in intensive care units or step-down
241	units receive 24-hour inpatient general medical services, post-
242	surgical services, or both general medical and post-surgical
243	services. These units may include mixed patient populations of
244	diverse diagnoses and diverse age groups.
245	(k)  No more than four patients may be assigned to each
246	registered nurse, so that the minimum registered nurse-to-
247	patient ratio in a specialty care unit is 1 to 4 or fewer at any
248	time. As used in this paragraph, the term "specialty care unit"
249	means a unit that is organized, operated, and maintained to
250	provide care for a specific medical condition or a specific
251	patient population, is more comprehensive for the specific
252	condition or disease process than the care that is available on
253	medical/surgical units, and is not otherwise covered in this
254	section.
255	(l)  No more than four patients may be assigned to each
256	registered nurse, so that the minimum registered nurse-to-
257	patient ratio in an acute care psychiatric unit is 1 to 4 or
258	fewer at any time.
259
260	Identifying a unit by a name or term other than those used in
261	this subsection does not affect the requirement to provide staff
262	for the unit at the ratio required for the level or type of care
263	provided in the unit, as set forth in this subsection.
264	(3)  STAFFING PLAN.--Each facility licensed under this
265	chapter shall ensure that it provides sufficient, appropriately
266	qualified nursing staff of each classification in each
267	department or unit within the facility in order to meet the
268	individualized care needs of the patients. To accomplish this
269	goal, each health care facility licensed under this chapter
270	shall submit annually to the agency a documented staffing plan
271	together with a written certification that the staffing plan is
272	sufficient to provide adequate and appropriate delivery of
273	health care services to patients for the ensuing year. The
274	staffing plan must:
275	(a)  Meet the minimum requirements set forth in subsection
276	(2);
277	(b)  Be adequate to meet any additional requirements
278	provided by other laws or rules;
279	(c)  Employ and identify an approved acuity system for
280	addressing fluctuations in actual patient acuity levels and
281	nursing care requirements requiring increased staffing levels
282	above the minimums set forth in the plan;
283	(d)  Factor in other unit or department activity, such as
284	discharges, transfers and admissions, and administrative support
285	tasks, which direct-care nurses are expected to do in addition
286	to performing direct nursing care;
287	(e)  Identify the assessment tool used to validate the
288	acuity system relied on in the plan;
289	(f)  Identify the system that will be used to document
290	actual daily staffing levels within each department or unit;
291	(g)  Include a written assessment of the accuracy of the
292	previous year's staffing plan in light of actual staffing needs;
293	(h)  Identify each nurse staff classification referenced in
294	the staffing plan, together with a statement setting forth
295	minimum qualifications for each such classification; and
296	(i)  Be developed in consultation with the direct-care
297	nursing staff within each department or unit or, if such staff
298	is covered by a collective bargaining agreement, with the
299	applicable recognized or certified collective bargaining
300	representatives of the direct-care nursing staff.
301	(4)  MINIMUM SKILL MIX.--The skill mix reflected in a
302	documented staffing plan must ensure that all of the following
303	elements of the nursing process are performed in the planning
304	and delivery of care for each patient: assessment, nursing
305	diagnosis, planning, intervention, evaluation, and patient
306	advocacy.
307	(a)  The skill mix may not incorporate or assume that
308	nursing care functions that are required by licensing law or
309	rules or accepted standards of practice to be performed by a
310	licensed nurse are to be performed by unlicensed assistant
311	personnel.
312	(b)  A nurse may not be assigned or included in the count
313	of assigned nursing staff for purposes of compliance with
314	minimum staffing requirements in a nursing department or unit or
315	a clinical area within the health care facility unless the nurse
316	is qualified in the area of practice to which the nurse is
317	assigned.
318	(5)  COMPLIANCE WITH PLAN.--As a condition of licensing, a
319	health care facility must at all times provide staff in
320	accordance with its documented staffing plan and the staffing
321	standards set forth in this section; however, this section does
322	not preclude a health care facility from implementing higher
323	direct-care, nurse-to-patient staffing levels.
324	(6)  RECORDKEEPING.--The facility shall maintain records
325	sufficient to allow the agency to determine the daily staffing
326	ratios and skill mixes that the facility has maintained on each
327	unit.
328	Section 5.  Section 395.055, Florida Statutes, is created
329	to read:
330	395.055  Mandatory overtime.--
331	(1)  An employee of a health care facility may not be
332	required to work overtime as defined in s. 395.053. Compelling
333	or attempting to compel an employee to work overtime is contrary
334	to public policy and is a violation of this section. The
335	acceptance by any employee of overtime work is strictly
336	voluntary, and the refusal of an employee to accept such
337	overtime work may not be grounds for discrimination, dismissal,
338	discharge, or any other penalty; threats of reports for
339	discipline; or employment decisions adverse to the employee.
340	(2)  This section does not apply to work that occurs:
341	(a)  Because of an unforeseeable emergent circumstance;
342	(b)  During prescheduled on-call time if, as of July 1,
343	2006, such prescheduled on-call time was a customary and
344	longstanding practice in the unit or department of the health
345	care facility; or
346	(c)  Because of unpredictable and unavoidable occurrences
347	relating to health care delivery which occur at unscheduled
348	intervals and require immediate action, if the employer shows
349	that the employer has exhausted reasonable efforts to comply
350	with the documented staffing plan. An employer has not used
351	reasonable efforts if overtime work is used to fill vacancies
352	resulting from chronic staff shortages.
353	(3)  This section does not prohibit a health care employee
354	from voluntarily working overtime.
355	Section 6.  Section 395.056, Florida Statutes, is created
356	to read:
357	395.056  Employee rights.--
358	(1)  A health care facility may not penalize, discriminate
359	against, or retaliate in any manner against a direct-care
360	registered nurse for refusing an assignment that would violate
361	requirements set forth in this act.
362	(2)  A health care facility may not penalize, discriminate
363	against, or retaliate in any manner against an employee with
364	respect to compensation for, or terms, conditions, or privileges
365	of, employment if such an employee in good faith, individually
366	or in conjunction with another person or persons:
367	(a)  Reports a violation or suspected violation of this act
368	to a regulatory agency, a private accreditation body, or
369	management personnel of the health care facility;
370	(b)  Initiates, cooperates in, or otherwise participates in
371	an investigation or proceeding brought by a regulatory agency or
372	private accreditation body concerning matters covered by this
373	act;
374	(c)  Informs or discusses with any other employee, with any
375	representative of the employees, with a patient or patient
376	representative, or with the public violations or suspected
377	violations of this act; or
378	(d)  Otherwise avails himself or herself of the rights set
379	forth in this act.
380	(3)  For purposes of this section, an employee is acting in
381	good faith if the employee reasonably believes that the
382	information reported or disclosed is true and that a violation
383	has occurred or may occur.
384	Section 7.  Section 395.057, Florida Statutes, is created
385	to read:
386	395.057  Implementation and enforcement.--
387	(1)  The agency shall enforce compliance with the staffing
388	plans and standards set forth in this act. The agency may adopt
389	rules necessary to administer this act. At a minimum, the rules
390	must provide for:
391	(a)  Unannounced, random compliance site visits to licensed
392	health care facilities subject to this act;
393	(b)  An accessible and confidential system by which the
394	public and nursing staff can report a health care facility's
395	failure to comply with this act;
396	(c)  A systematic means of investigating and correcting
397	violations of this act;
398	(d)  A graduated system of penalties, including fines,
399	withholding of reimbursement, suspension of admission to
400	specific units, and other appropriate measures, if violations
401	are not corrected; and
402	(e)  Public access to information regarding reports of
403	inspections, results, deficiencies, and corrections.
404	(2)  The agency shall develop rules for administering this
405	act which require compliance with staffing standards for
406	critical care units by July 1, 2007, and compliance with all
407	provisions of this act by July 1, 2009.
408	Section 8.  This act shall take effect July 1, 2006.

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