1Amending the act of July 19, 1979 (P.L.130, No.48), entitled "An
2act relating to health care; prescribing the powers and
3duties of the Department of Health; establishing and
4providing the powers and duties of the State Health
5Coordinating Council, health systems agencies and Health Care
6Policy Board in the Department of Health, and State Health
7Facility Hearing Board in the Department of Justice;
8providing for certification of need of health care providers
9and prescribing penalties," providing for hospital patient
10protection.

11The General Assembly of the Commonwealth of Pennsylvania
12hereby enacts as follows:

13Section 1. The act of July 19, 1979 (P.L.130, No.48), known
14as the Health Care Facilities Act, is amended by adding a
15chapter to read:

16CHAPTER 8-A

17HOSPITAL PATIENT PROTECTION

18Section 831-A. Scope of chapter.

19This chapter provides for hospital patient protection.

20Section 832-A. Purpose.

1The General Assembly finds that:

2(1) Health care services are becoming more complex, and
3it is increasingly difficult for patients to access
4integrated services.

5(2) Competent, safe, therapeutic and effective patient
6care is jeopardized because of staffing changes implemented
7in response to market-driven managed care.

8(3) To ensure effective protection of patients in acute
9care settings, it is essential that qualified direct care
10registered nurses be accessible and available to meet the
11individual needs of patients at all times.

12(4) To ensure the health and welfare of Pennsylvania
13citizens, mandatory hospital direct care professional nursing
14practice standards and professional practice protections must
15be established to assure that hospital nursing care is
16provided in the exclusive interests of patients.

17(5) Direct care registered nurses have a fiduciary duty
18to assigned patients and necessary duty and right of patient
19advocacy and collective patient advocacy to satisfy
20professional fiduciary obligations.

21(6) The basic principles of staffing in hospital
22settings should be based on the individual patient's care
23needs, the severity of the condition, services needed and the
24complexity surrounding those services.

25(7) Current unsafe hospital direct care registered nurse
26staffing practices have resulted in adverse patient outcome.

27(8) Mandating adoption of uniform, minimum, numerical
28and specific registered nurse-to-patient staffing ratios by
29licensed hospital facilities is necessary for competent,
30safe, therapeutic and effective professional nursing care and

1for retention and recruitment of qualified direct care
2registered nurses.

3(9) Direct care registered nurses must be able to
4advocate for their patients without fear of retaliation from
5their employer.

6(10) Whistleblower protections that encourage registered
7nurses and patients to notify government and private
8accreditation entities of suspected unsafe patient
9conditions, including protection against retaliation for
10refusing unsafe patient care assignments by competent
11registered nurse staff, will greatly enhance the health,
12welfare and safety of patients.

13Section 833-A. Definitions.

14The following words and phrases when used in this chapter
15shall have the meaning given to them in this section unless the
16context clearly indicates otherwise:

17"Acuity-based patient classification system" or "system." A
18standardized set of criteria based on scientific data that acts
19as a measurement instrument used to predict registered nursing
20care requirements for individual patients based on:

21(1) The severity of patient illness.

22(2) The need for specialized equipment and technology.

23(3) The intensity of required nursing interventions.

24(4) The complexity of clinical nursing judgment required
25to design, implement and evaluate the patient's nursing care
26plan consistent with professional standards.

27(5) The ability for self-care, including motor, sensory
28and cognitive deficits.

29(6) The need for advocacy intervention.

30(7) The licensure of the personnel required for care.

1(8) The patient care delivery system.

2(9) The unit's geographic layout.

3(10) Generally accepted standards of nursing practice,
4as well as elements reflective of the unique nature of the
5acute care hospital's patient population.

6The system determines the additional number of direct care
7registered nurses and other licensed and unlicensed nursing
8staff the hospital must assign, based on the independent
9professional judgment of the direct care registered nurse, to
10meet the individual patient needs at all times.

11"Artificial life support." A system that uses medical
12technology to aid, support or replace a vital function of the
13body that has been seriously damaged.

14"Clinical judgment." The application of a direct care
15registered nurse's knowledge, skill, expertise and experience in
16making independent decisions about patient care.

17"Clinical supervision." The assignment and direction of
18patient care tasks required in the implementation of nursing
19care for a patient to other licensed nursing staff or to
20unlicensed staff by a direct care registered nurse in the
21exclusive interests of the patient.

22"Competence." The current documented, demonstrated and
23validated ability of a direct care registered nurse to act and
24integrate the knowledge, skills, abilities and independent
25professional judgment that underpin safe, therapeutic and
26effective patient care and which ability is based on the
27satisfactory performance of:

28(1) The statutorily recognized duties and
29responsibilities of the registered nurses as provided under
30the laws of this Commonwealth.

1(2) The standards required under this chapter which are
2specific to each hospital unit.

3"Critical access hospital." A health facility designated
4under a Medicare rural hospital flexibility program established
5by the Commonwealth and as defined in section 1861(mm) of the
6Social Security Act (49 Stat. 620, 42 U.S.C. § 1395x(mm)).

7"Critical care unit" or "intensive care unit." A nursing
8unit of an acute care hospital that is established to safeguard
9and protect patients whose severity of medical conditions
10require continuous monitoring and complex interventions by
11direct care registered nurses and whose restorative measures
12require complex monitoring, intensive intricate assessment,
13evaluation, specialized rapid intervention and the education and
14teaching of the patient, the patient's family or other
15representatives by a competent and experienced direct care
16registered nurse. The term includes an intensive care unit, a
17burn center, a coronary care unit or an acute respiratory unit.

18"Direct care registered nurse" or "direct care professional
19nurse." A registered nurse who:

20(1) Is currently licensed by the Pennsylvania Board of
21Nursing to engage in professional nursing with documented
22clinical competence as defined in the act of May 22, 1951
23(P.L. 317, No. 69), known as The Professional Nursing Law.

24(2) Has accepted a direct, hands-on patient care
25assignment to implement medical and nursing regimens and
26provide related clinical supervision of patient care while
27exercising independent professional judgment at all times in
28the interests of a patient.

29"Hospital." An entity located in this Commonwealth that is
30licensed as a hospital under this act. The term includes a

1critical access and long-term acute care hospital.

2"Hospital unit" or "clinical patient care area." An
3intensive care or critical care unit, a burn unit, a labor and
4delivery room, antepartum and postpartum, a newborn nursery, a
5post-anesthesia service area, an emergency department, an
6operating room, a pediatric unit, a step-down or intermediate
7care unit, a specialty care unit, a telemetry unit, a general
8medical/surgical care unit, a psychiatric unit, a rehabilitation
9unit or a skilled nursing facility unit.

10"Long-term acute care hospital." A hospital or health care
11facility that specializes in providing acute care to medically
12complex patients with an anticipated length of stay of more than
1325 days. The term includes a free-standing and a hospital-
14within-hospital model of a long-term acute care facility.

15"Medical/surgical unit." A unit that:

16(1) Is established to safeguard and protect patients
17whose severity of illness, including all comorbidities,
18restorative measures and level of nursing intensity requires
19continuous care through direct observation by a direct care
20registered nurse, monitoring, multiple assessments,
21specialized interventions, evaluations and the education or
22teaching of a patient's family or other representatives by a
23competent and experienced direct care registered nurse.

24(2) May include patients requiring less than intensive
25care or step-down care and patients receiving 24-hour
26inpatient general medical care, post-surgical care or both.

27(3) May include mixed patient populations of diverse
28diagnoses and diverse age groups, excluding pediatric
29patients.

30"Patient assessment." The direct care utilization by a

1registered nurse of critical thinking, which is the
2intellectually disciplined process of actively and skillfully
3interpreting, applying, analyzing, synthesizing and evaluating
4data obtained through the registered nurse's direct care, direct
5observation and communication with others.

6"Professional judgment." The educated, informed and
7experienced process that a direct care registered nurse
8exercises in forming an opinion and reaching a clinical
9decision, in a patient's best interest, based upon analysis of
10data, information and scientific evidence.

11"Rehabilitation unit." A functional clinical unit for the
12provision of those rehabilitation services that restore an ill
13or injured patient to the highest level of self-sufficiency or
14gainful employment of which the patient is capable in the
15shortest possible time, compatible with the patient's physical,
16intellectual and emotional or psychological capabilities and in
17accordance with planned goals and objectives.

18"Skilled nursing facility." A functional clinical unit that:

19(1) Provides skilled nursing care and supportive care to
20patients whose primary need is for the availability of
21skilled nursing care on a long-term basis and who are
22admitted after at least a 48-hour period of continuous
23inpatient care.

24(2) Provides at least the following: medical, nursing,
25dietary, pharmaceutical services and an activity program.

26"Specialty care unit." A unit that:

27(1) Is established to safeguard and protect patients
28whose severity of illness, including all comorbidities,
29restorative measures and level of nursing intensity requires
30continuous care through direct observation by a direct care

1registered nurse, monitoring, multiple assessments,
2specialized interventions, evaluations and the education and
3teaching of a patient's family or other representatives by a
4competent and experienced direct care registered nurse.

5(2) Provides intensity of care for a specific medical
6condition or a specific patient population.

7(3) Is more comprehensive for the specific condition or
8disease process than that which is required on a
9medical/surgical unit and is not otherwise covered by the
10definitions in this section.

11"Step-down unit." A unit established:

12(1) To safeguard and protect patients whose severity of
13illness, including all comorbidities, restorative measures
14and level of nursing intensity requires intermediate
15intensive care through direct observation by the direct care
16registered nurse, monitoring, multiple assessments,
17specialized interventions, evaluations and the education and
18teaching of the patient's family or other representatives by
19a competent and experienced direct care registered nurse.

20(2) To provide care to patients with moderate or
21potentially severe physiologic instability requiring
22technical support but not necessarily artificial life
23support.

24"Technical support." Specialized equipment and direct care
25registered nurses providing for invasive monitoring, telemetry
26and mechanical ventilation for the immediate amelioration or
27remediation of severe pathology for those patients requiring
28less care than intensive care, but more care than that which is
29required from medical/surgical care.

30"Telemetry unit." A unit that:

1(1) Is established to safeguard and protect patients
2whose severity of illness, including all comorbidities,
3restorative measures and level of nursing intensity requires
4intermediate intensive care through direct observation by a
5direct registered nurse, monitoring, multiple assessments,
6specialized interventions, evaluations and the education and
7teaching of a patient's family or other representatives by a
8competent and experienced direct care registered nurse.

9(2) Is designated for the electronic monitoring,
10recording, retrieval and display of cardiac electrical
11signals.

12Section 834-A. Hospital nursing practice standard.

13(a) Professional obligation and right.--By virtue of their
14professional license and ethical obligations, all registered
15nurses have a duty and right to act and provide care in the
16exclusive interests of a patient and to act as the patient's
17advocate, as circumstances require, in accordance with the
18provision described in section 836-A.

19(b) Acceptance of patient care assignments.--

20(1) A direct care registered nurse shall provide
21competent, safe, therapeutic and effective nursing care to
22assigned patients.

23(2) As a condition of licensure, a health care facility
24shall adopt, disseminate to direct care nurses and comply
25with a written policy that details the circumstances under
26which a direct care nurse may refuse a work assignment.

27(3) At a minimum, the policy shall permit a direct care
28nurse to refuse a patient assignment for which:

29(i) the nurse does not have the necessary knowledge,
30judgment, skills and ability to provide the required care

1without compromising or jeopardizing the patient's
2safety, the nurse's ability to meet foreseeable patient
3needs or the nurse's license; and

4(ii) the assignment otherwise would violate
5requirements under this chapter.

6(4) At a minimum, the policy shall permit a direct care
7nurse to assess an order initiated by a physician or legally
8authorized health care professional before implementation to
9determine if the order is:

10(i) in the best interests of the patient;

11(ii) initiated by a person legally authorized to
12issue the order; and

13(iii) in accordance with applicable law and
14regulation governing nursing care.

15(5) At a minimum, the work assignment policy shall
16contain procedures for the following:

17(i) Reasonable requirements for prior notice to the
18nurse's supervisor regarding the nurse's request and
19supporting reasons for being relieved of the assignment,
20continued duty or implementation of an order.

21(ii) If feasible, an opportunity for the supervisor
22to review the specific conditions supporting the nurse's
23request and to decide whether to:

24(A) remedy the conditions;

25(B) to relieve the nurse of the assignment or
26order; or

27(C) deny the nurse's request to be relieved of
28the assignment, continued duty or implementation of
29an order.

30(iii) A process that permits the nurse to exercise

1the right to refuse the assignment, continued on-duty
2status or implementation of an order when the supervisor
3denies the request to be relieved if:

4(A) The supervisor rejects the request without
5proposing a remedy or the proposed remedy would be
6inadequate or untimely.

7(B) The complaint and investigation process with
8a regulatory agency would be untimely to address
9concern.

10(C) The employee, in good faith, believes that
11the assignment or implementation of an order meets
12conditions justifying refusal.

13(iv) A nurse who refuses an assignment or
14implementation of an order under a work assignment policy
15established in this section shall not be deemed, by
16reason thereof, to have engaged in negligent or
17incompetent action, patient abandonment or otherwise to
18have violated applicable nursing law.

19Section 835-A. Professional duty of patient advocacy.

20A registered nurse has the duty to act as a patient's
21advocate as circumstances require by:

22(1) initiating action to improve health care or to
23change decisions or activities which in the professional
24judgment of the direct care registered nurse are against the
25interests or wishes of the patient; or

26(2) giving the patient the opportunity to make informed
27decisions about health care before it is provided.

28Section 836-A. Free speech.

29(a) Prohibition against discharge or retaliation for
30whistleblowing.--A hospital or other health care facility shall

1not discharge from duty or otherwise retaliate against a direct
2care registered nurse or other health care professional
3responsible for patient care who reports unsafe practices or
4violation of policy, regulation, rule or law.

5(b) Rights guaranteed as essential to effective patient
6advocacy.--

7(1) A direct care registered nurse or other health care
8professional or worker responsible for patient care in a
9hospital shall enjoy the right of free speech and shall be
10protected in the exercise of that right as provided in this
11section, both during working hours and during off-duty hours.

12(2) The right of free speech protected by this section
13is a necessary incident of the professional nurse duty of
14patient advocacy and is essential to protecting the health
15and safety of hospital patients and of the people of this
16Commonwealth.

17(c) Protected speech.--

18(1) The "free speech" protected by this section
19includes, without limitation, any type of spoken, gestured,
20written, printed or electronically communicated expression
21concerning any matter related to or affecting competent,
22safe, therapeutic and effective nursing care by direct care
23registered nurses or other health care professionals and
24workers at the hospital facility, at facilities within large
25health delivery systems or corporate chains which include the
26hospital, or more generally within the health care industry.

27(2) The content of speech protected by this section
28includes, without limitation, the facts and circumstances of
29particular events, patient care practices, institutional
30actions, policies or conditions which may facilitate or

1impede competent, safe, therapeutic and effective nursing
2practice and patient care, adverse patient outcomes or
3incidents, sentinel and reportable events and arguments in
4support of or against hospital policies or practices relating
5to the delivery of nursing care.

6(3) Protected speech under this section includes the
7reporting, internally, externally or publicly, of actions,
8conduct, events, practices or other matters that are believed
9to constitute:

10(i) a violation of Federal, State or local laws or
11regulations;

12(ii) a breach of applicable codes of professional
13ethics, including the professional and ethical
14obligations of direct care registered nurses;

15(iii) matters which, in the independent judgment of
16the reporting direct care registered nurse, are
17appropriate or required for disclosure in furtherance and
18support of the nurse's exercise of patient advocacy
19duties to improve health care or change decisions or
20activities which, in the professional judgment of the
21direct care registered nurse, are against the interests
22or wishes of the patient or to ensure that the patient is
23afforded a meaningful opportunity to make informed
24decisions about health care before it is provided; or

25(iv) concern matters as described in subparagraph
26(iii) made in aid and support of the exercise of patient
27advocacy duties of direct care registered nurse
28colleagues.

29(d) Nondisclosure of confidential information.--Nothing in
30this section shall be construed to authorize disclosure of

1private and confidential patient information except where such
2disclosure is:

3(1) required by law;

4(2) compelled by proper legal process;

5(3) consented to by the patient; or

6(4) provided in confidence to regulatory or
7accreditation agencies or other government entities for
8investigatory purposes or under formal or informal complaints
9of unlawful or improper practices for purposes of achieving
10corrective and remedial action.

11(e) Duty of patient advocacy.--Engaging in free speech
12activity as described in this section constitutes an exercise of
13the direct care registered nurse's duty and right of patient
14advocacy. The subject matter of free speech activity as
15described in this section is presumed to be a matter of public
16concern, and the disclosures protected under this section are
17presumed to be in the public interest.

18Section 837-A. Protected rights.

19(a) General rule.--Any person shall have the right to:

20(1) Oppose policies, practices or actions of any
21hospital or other medical facility that are alleged to
22violate, breach or fail to comply with any provision of this
23chapter;

24(2) Cooperate, provide evidence, testify or otherwise
25support or participate in any investigation or complaint
26proceeding under sections 845-A and 846-A.

27(b) Right to file complaint.--

28(1) A patient of a hospital or other medical facility
29aggrieved by the hospital's or facility's interference with
30the full and free exercise of patient advocacy duties by a

1direct care registered nurse shall have the right to make or
2file a complaint, cooperate, provide evidence, testify or
3otherwise support or participate in any investigation or
4complaint proceeding under sections 845-A and 846-A.

5(2) A direct care registered nurse of a hospital or
6other medical facility aggrieved by the hospital's or
7facility's interference with the full and free exercise of
8patient advocacy duties shall have the right to make or file
9a complaint, cooperate, provide evidence, testify or
10otherwise support or participate in any investigation or
11complaint proceeding under sections 845-A and 846-A.

12Section 838-A. Interference with rights and duties of free
13speech and patient advocacy prohibited.

14No hospital or other medical facility employer or its agents
15may:

16(1) interfere with, restrain, coerce, intimidate or deny
17the exercise of or the attempt to exercise, by any person of
18any right provided or protected under this chapter; or

19(2) discriminate or retaliate against any person for
20opposing any policy, practice or action of the hospital or
21other medical facility which is alleged to violate, breach or
22fail to comply with any provisions of this chapter.

23Section 839-A. No retaliation or discrimination for protected
24actions.

25No hospital or other medical facility employer may
26discriminate or retaliate in any manner against any patient,
27employee or contract employee of the hospital or other medical
28facility or any other person because that person has:

29(1) presented a grievance or complaint or has initiated
30or cooperated in any investigation or proceeding of any

1governmental entity, regulatory agency or private
2accreditation body; or

3(2) made a civil claim or demand or filed an action
4relating to the care, services or conditions of the hospital
5or of any affiliated or related facilities.

6Section 840-A. Direct care registered nurse-to-patient staffing
7ratios.

8(a) General requirements.--A hospital shall provide minimum
9staffing by direct care registered nurses in accordance with the
10general requirements of this subsection and the clinical unit or
11clinical patient care area direct care registered nurse-to-
12patient ratios specified in subsection (b). Staffing for patient
13care tasks not requiring a direct care registered nurse is not
14included within these ratios and shall be determined under an
15acuity-based patient classification system, this section and
16section 841-A. The requirements are as follows:

17(1) No hospital may assign a direct care registered
18nurse to a nursing unit or clinical area unless that hospital
19and the direct care registered nurse determine that the
20direct care registered nurse has demonstrated and validated
21current competence in providing care in that area and has
22also received orientation to that hospital's clinical area
23sufficient to provide competent, safe, therapeutic and
24effective care to patients in that area. The policies and
25procedures of the hospital shall contain the hospital's
26criteria for making this determination.

27(2) (i) Direct care registered nurse-to-patient ratios
28represent the maximum number of patients that shall be
29assigned to one direct care registered nurse at all
30times.

1(ii) For purposes of this paragraph, "assigned"
2means the direct care registered nurse has responsibility
3for the provision of care to a particular patient within
4the direct care registered nurse's validated competency.

5(3) There shall be no averaging of the number of
6patients and the total number of direct care registered
7nurses on the unit during any one shift nor over any period
8of time.

9(4) Only direct care registered nurses providing direct
10patient care shall be included in the ratios. Nurse
11administrators, nurse supervisors, nurse managers, charge
12nurses and case managers shall not be included in the
13calculation of the direct care registered nurse-to-patient
14ratio. Only direct care registered nurses shall relieve other
15direct care registered nurses during breaks, meals and other
16routine, expected absences from the unit.

17(5) Only direct care registered nurses shall be assigned
18to intensive care newborn nursery service units, which
19specifically require one direct care registered nurse to two
20or fewer infants at all times.

21(6) In the emergency department, only direct care
22registered nurses shall be assigned to triage patients, and
23only direct care registered nurses shall be assigned to
24critical trauma patients.

25(b) Unit or patient care areas.--

26(1) The minimum staffing ratios for general, acute,
27critical access and specialty hospitals are established in
28this subsection for direct care registered nurses as follows:

29(i) The direct care registered nurse-to-patient
30ratio in an intensive care unit shall be 1:2 or fewer at

1all times.

2(ii) The direct care registered nurse-to-patient
3ratio for a critical care unit shall be 1:2 or fewer at
4all times.

5(iii) The direct care registered nurse-to-patient
6ratio for a neonatal intensive care unit shall be 1:2 or
7fewer at all times.

8(iv) The direct care registered nurse-to-patient
9ratio for a burn unit shall be 1:2 or fewer at all times.

10(v) The direct care registered nurse-to-patient
11ratio for a step-down, intermediate care unit shall be
121:3 or fewer at all times.

13(vi) An operating room shall have at least one
14direct care registered nurse assigned to the duties of
15the circulating registered nurse and a minimum of one
16additional person as a scrub assistant for each patient-
17occupied operating room.

18(vii) The direct care registered nurse-to-patient
19ratio in the postanesthesia recovery unit of an
20anesthesia service shall be 1:2 or fewer at all times,
21regardless of the type of anesthesia the patient
22received.

23(viii) The direct care registered nurse-to-patient
24ratio for patients receiving conscious sedation shall be
251:1 at all times.

26(ix) (A) The direct care registered nurse-to-
27patient ratio for an emergency department shall be
281:4 or fewer at all times.

29(B) The direct care registered nurse-to-patient
30ratio for critical care patients in the emergency

1department shall be 1:2 or fewer at all times.

2(C) Only direct care registered nurses shall be
3assigned to critical trauma patients in the emergency
4department, and a minimum direct care registered
5nurse-to-critical trauma patient ratio of 1:1 shall
6be maintained at all times.

7(D) In an emergency department, triage, radio or
8specialty/flight, registered nurses do not count in
9the calculation of direct care registered nurse-to-
10patient ratio.

11(x) (A) The direct care registered nurse-to-patient
12ratio in the labor and delivery suite of prenatal
13services shall be 1:1 at all times for active labor
14patients and patients with medical or obstetrical
15complications.

16(B) The direct care registered nurse-to-patient
17ratio shall be 1:1 at all times for initiating
18epidural anesthesia and circulation for cesarean
19delivery.

20(C) The direct care registered nurse-to-patient
21ratio for patients in immediate postpartum shall be
221:2 or fewer at all times.

23(xi) (A) The direct care registered nurse-to-
24patient ratio for antepartum patients who are not in
25active labor shall be 1:3 or fewer at all times.

26(B) The direct care registered nurse-to-patient
27ratio for patients in a postpartum area of the
28prenatal service shall be 1:3 mother-baby couplets or
29fewer at all times.

30(C) In the event of cesarean delivery, the total

1number of mothers plus infants assigned to a single
2direct care registered nurse shall never exceed four.

3(D) In the event of multiple births, the total
4number of mothers plus infants assigned to a single
5direct care registered nurse shall not exceed six.

6(E) For postpartum areas in which the direct
7care registered nurse's assignment consists of
8mothers only, the direct care registered nurse-to-
9patient ratio shall be 1:4 or fewer at all times.

10(F) The direct care registered nurse-to-patient
11ratio for postpartum women or postsurgical
12gynecological patients shall be 1:4 or fewer at all
13times.

14(G) Well baby nursery direct care registered
15nurse ratio shall be 1:5 or fewer at all times.

16(H) The direct care registered nurse-to-patient
17ratio for unstable newborns and those in the
18resuscitation period as assessed by the direct care
19registered nurse shall be 1:1 at all times.

20(I) The direct care registered nurse-to-patient
21ratio for recently born infants shall be 1:4 or fewer
22at all times.

23(xii) The direct care registered nurse-to-patient
24ratio for pediatrics shall be 1:3 or fewer at all times.

25(xiii) The direct care registered nurse-to-patient
26ratio in telemetry shall be 1:3 or fewer at all times.

27(xiv) (A) The direct care registered nurse-to-
28patient ratio in medical/surgical shall be 1:4 or
29fewer at all times.

30(B) The direct care registered nurse-to-patient

1ratios for presurgical and admissions units or
2ambulatory surgical units shall be 1:4 or fewer at
3all times.

4(xv) The direct care registered nurse-to-patient
5ratio in other specialty units shall be 1:4 or fewer at
6all times.

7(xvi) The direct care registered nurse-to-patient
8ratio in psychiatric units shall be 1:4 or fewer at all
9times.

10(xvii) The direct care registered nurse-to-patient
11ratio in a rehabilitation unit or a skilled nursing
12facility shall be 1:5 or fewer at all times.

13(c) Additional conditions.--

14(1) Identifying a unit or clinical patient care area by
15a name or term other than those defined in section 833-A does
16not affect the requirement to staff at the direct care
17registered nurse-to-patient ratios identified for the level
18of intensity or type of care described in section 833-A and
19this section.

20(2) (i) Patients shall only be cared for on units or
21clinical patient care areas where the level of intensity,
22type of care and direct care registered nurse-to-patients
23ratios meet the individual requirements and needs of each
24patient.

25(ii) The use of patient acuity-adjustable units or
26clinical patient care areas is prohibited.

27(3) Video cameras or monitors or any form of electronic
28visualization of a patient shall not be deemed a substitute
29for the direct observation required for patient assessment by
30the direct care registered nurse and for patient protection

1required by an attendant or sitter.

2Section 841-A. Hospital unit staffing plans.

3(a) Acuity-based patient classification system.--

4(1) In addition to the direct care registered nurse
5ratio requirements of subsection (b), a hospital shall assign
6additional nursing staff, such as licensed practical nurses
7and certified nursing assistants, through the implementation
8of a valid acuity-based patient classification system for
9determining nursing care needs of individual patients that
10reflects the assessment made by the assigned direct care
11registered nurse of patient nursing care requirements and
12provides for shift-by-shift staffing based on those
13requirements.

14(2) The ratios specified in subsection (b) shall
15constitute the minimum number of registered nurses who shall
16be assigned to direct patient care. Additional registered
17nursing staff in excess of the prescribed ratios shall be
18assigned to direct patient care in accordance with the
19hospital's implementation of a valid system for determining
20nursing care requirements.

21(3) Based on the direct care registered nurse assessment
22as reflected in the implementation of a valid system and
23independent direct care registered nurse determination of
24patient care needs, additional licensed and nonlicensed staff
25shall be assigned.

26(b) Development of written staffing plan.--

27(1) A written staffing plan shall be developed by the
28chief nursing officer or a designee, based on individual
29patient care needs determined by the system. The staffing
30plan shall be developed and implemented for each patient care

1unit and shall specify individual patient care requirements
2and the staffing levels for direct care registered nurses and
3other licensed and unlicensed personnel.

4(2) In no case shall the staffing level for direct care
5registered nurses on any shifts fall below the requirements
6of this subsection.

7(3) The plan shall include the following:

8(i) Staffing requirements as determined by the
9system for each unit, documented and posted on the unit
10for public view on a day-to-day, shift-by-shift basis.

11(ii) The actual staff and staff mix provided,
12documented and posted on the unit for public view on a
13day-to-day, shift-by-shift basis.

14(iii) The variance between required and actual
15staffing patterns, documented and posted on the unit for
16public view on a day-to-day, shift-by-shift basis.

17(c) Recordkeeping.--In addition to the documentation
18required in subsection (b), the hospital shall keep a record of
19the actual direct care registered nurse, licensed practical
20nurse and certified nursing assistant assignments to individual
21patients by licensure category, documented on a day-to-day,
22shift-by-shift basis. The hospital shall retain:

23(1) The staffing plan required in subsection (b) for a
24period of two years.

25(2) The record of the actual direct care registered
26nurse, licensed practical nurse and certified nursing
27assistant assignments by licensure and nonlicensure category.

28(d) Review committee to conduct annual review of system.--
29The reliability of the system for validating staffing
30requirements shall be reviewed at least annually by a committee

1to determine whether the system accurately measures individual
2patient care needs and completely predicts direct care
3registered nurse, licensed practical nurse and certified nursing
4assistant staffing requirements based exclusively on individual
5patient needs.

6(e) Review committee membership.--

7(1) At least half of the members of the review committee
8shall be unit-specific, competent direct care registered
9nurses who provide direct patient care.

10(2) The members of the committee shall be appointed by
11the chief nurse officer, except where direct care registered
12nurses are represented for collective bargaining purposes,
13all direct care registered nurses on the committee shall be
14appointed by the authorized collective bargaining agent.

15(3) In case of a dispute, the direct care registered
16nurse assessment shall prevail.

17(f) Time period for adjustments.--If the review committee
18determines that adjustments are necessary in order to assure
19accuracy in measuring patient care needs, the adjustments shall
20be implemented within 30 days of that determination.

21(g) Process for staff input.--A hospital shall develop and
22document a process by which all interested staff may provide
23input about the system's required revisions and the overall
24staffing plan.

25(h) Limitation on administrator of nursing services.--The
26administrator of nursing services may not be designated to serve
27as a charge nurse or to have direct patient care responsibility.

28(i) Minimum requirement for each shift.--Each patient care
29unit shall have at least one direct care registered nurse
30assigned, present and responsible for the patient care in the

1unit on each shift.

2(j) Temporary nursing agencies.--

3(1) Nursing personnel from temporary nursing agencies
4may not be responsible for patient care on any clinical unit
5without having demonstrated and validated clinical competency
6on the assigned unit.

7(2) A hospital that utilizes temporary nursing agencies
8shall have and adhere to a written procedure to orient and
9evaluate personnel from these sources. In order to ensure
10clinical competence of temporary agency personnel, the
11procedures shall require that personnel from temporary
12nursing agencies be evaluated as often, or more often, than
13staff employed directly by the hospital.

14(k) Planning for routine fluctuations.--

15(1) A hospital shall plan for routine fluctuations, such
16as admissions, discharges and transfers in patient census.

17(2) If a health care emergency causes a change in the
18number of patients on a unit, the hospital shall demonstrate
19that immediate and diligent efforts were made to maintain
20required staffing levels.

21(3) For purposes of this subsection, a "health care"
22emergency is defined as an emergency declared by the Federal
23Government or the head of a State, local, county or municipal
24government.

25Section 842-A. Minimum requirements for hospital systems.

26(a) General rule.--A hospital shall:

27(1) Adopt an acuity-based patient classification system,
28including a written nursing care staffing plan for each
29patient care unit.

30(2) Implement, evaluate and modify the plan as necessary

1and appropriate under the provisions of this section.

2(3) Provide direct care nurse staffing based on
3individual patient need determined in accordance with the
4requirements of this section.

5(4) Use the system to determine additional direct care
6registered nursing staffing above the minimum staffing ratios
7required by subsection (b) and any staffing by licensed
8practical nurses or unlicensed nursing personnel.

9(b) Required elements.--The system used by a hospital for
10determining patient nursing care needs shall include, but not be
11limited to, the following elements:

12(1) A method to predict nursing care requirements of
13individual patient assessments and as determined by direct
14care registered nurse assessments of individual patients.

15(2) A method that provides for sufficient direct care
16registered nursing staffing to ensure that all of the
17elements in this subsection are performed in the planning and
18delivery of care for each patient: assessment, nursing
19diagnosis, planning and intervention.

20(3) An established method by which the amount of nursing
21care needed for each category of patient is validated.

22(4) A method for validation of the reliability of the
23system.

24(c) Transparency of system.--

25(1) A system shall be fully transparent in all respects,
26including:

27(i) Disclosure of detailed documentation of the
28methodology used by the system to predict nursing
29staffing.

30(ii) Identification of each factor, assumption and

1value used in applying the methodology.

2(iii) An explanation of the scientific and empirical
3basis for each such assumption and value and
4certification by a knowledgeable and authorized
5representative of the hospital that the aforementioned
6disclosures regarding methods used for testing and
7validating the accuracy and reliability of the system are
8true and complete.

9(2) A hospital shall include in the documentation
10required by this section an evaluation and a report on at
11least an annual basis, which evaluation and report shall be
12conducted and prepared by a committee consisting exclusively
13of direct care registered nurses who have provided direct
14patient care in the units covered by the system. Where direct
15care registered nurses are represented for collective
16bargaining purposes, all direct care registered nurses on the
17committee shall be appointed by the authorized collective
18bargaining agent.

19(d) Submission to Department of Health.--

20(1) The documentation required by this section shall be
21submitted in its entirety to the Department of Health as a
22mandatory condition of hospital licensure, with a
23certification by the chief nurse officer for the hospital
24that it completely and accurately reflects implementation of
25a valid system used to determine nursing service staffing by
26the hospital for every shift on every clinical unit in which
27patients reside and receive care.

28(2) The certification shall be executed by the chief
29nurse officer under penalty of perjury and shall contain an
30express acknowledgment that any false statement in the

1certification shall constitute fraud and be subject to
2criminal and civil prosecution and penalties under the
3antifraud provisions applicable to false claims for
4government funds or benefits.

5(3) The documentation shall be available for public
6inspection in its entirety in accordance with procedures
7established by appropriate administrative regulation
8consistent with the purposes of this chapter.

9Section 843-A. Prohibited activities.

10(a) Prohibitions.--The following activities are prohibited:

11(1) A hospital shall not directly assign any unlicensed
12personnel to perform registered nurse functions in lieu of
13care delivered by a licensed registered nurse and shall not
14assign unlicensed personnel to perform registered nurse
15functions under the clinical supervision of a direct care
16registered nurse.

17(2) Unlicensed personnel may not perform tasks that
18require the clinical assessment, judgment and skill of a
19licensed registered nurse, including, without limitation:

20(i) Nursing activities that require nursing
21assessment and judgment during implementation.

22(ii) Physical, psychological and social assessments
23that require nursing judgment, intervention, referral or
24follow-up.

25(iii) Formulation of a plan of nursing care and
26evaluation of the patient's response to the care
27provided.

28(iv) Administration of medication, venipuncture or
29intravenous therapy, parenteral or tube feedings,
30invasive procedures, including inserting nasogastric

1tubes, inserting catheters or tracheal suctioning.

2(v) Educating patients and their families concerning
3the patient's health care problems, including
4postdischarge care.

5(b) Mandatory overtime.--A hospital shall not impose
6mandatory overtime requirements to meet the staffing ratios
7imposed in section 840-A.

8Section 844-A. Fines and civil penalties.

9The following fines and penalties shall apply to violations
10of this chapter:

11(1) A hospital found to have violated or aided and
12abetted section 841-A, 842-A or 843-A shall be subject, in
13addition to any other penalties that may be prescribed by
14law, to a civil penalty of not more than $25,000 for each
15violation and an additional $10,000 per nursing unit shift
16until the violation is corrected.

17(2) A hospital employer found to have violated or
18interfered with any of the rights or protections provided and
19guaranteed under sections 836-A, 837-A, 838-A, 839-A and

20840-A shall be subject to a civil penalty of not more than
21$25,000 for each such violation or occurrence of prohibited
22conduct.

23(3) Any hospital management, nursing service or medical
24personnel found to have violated or interfered with any of
25the rights or protections provided and guaranteed under
26sections 836-A, 837-A, 838-A, 839-A and 840-A shall be
27subject to a civil penalty of not more than $20,000 for each
28such violation or occurrence of prohibited conduct.

29Section 845-A. Private right of action.

30(a) General rule.--A health care facility that violates the

1rights of an employee specified in sections 835-A, 836-A, 837-A,
2838-A and 839-A may be held liable to the employee in an action
3brought in a court of competent jurisdiction for such legal or
4equitable relief as may be appropriate to effectuate the
5purposes of this chapter, including, but not limited to,
6reinstatement, promotion, lost wages and benefits and
7compensatory and consequential damages resulting from the
8violations together with an equal amount in liquidated damages.
9The court in the action shall, in addition to any judgment
10awarded to the plaintiffs, award reasonable attorney fees and
11costs of action to be paid by the defendants. The employee's
12right to institute a privation action is not limited by any
13other rights granted under this chapter.

14(b) Relief for nurses.--In addition to the amount recovered
15under subsection (d), a nurse whose employment is suspended or
16terminated in violation of this section is entitled to:

17(1) Reinstatement in the nurse's former position or
18severance pay in an amount equal to three months of the
19nurse's most recent salary.

20(2) Compensation for wages lost during the period of
21suspension or termination.

22(3) An award of reasonable attorney fees and costs as
23the prevailing party.

24Section 846-A. Enforcement procedure.

25(a) Period of limitations.--

26(1) Except as otherwise provided in paragraph (2), in
27the case of any action brought for a willful violation of the
28applicable provisions of this chapter, the action must be
29brought within three years of the date of the last event
30constituting the alleged violation for which such action is

1brought.

2(2) An action must be brought under section 845-A no
3later than two years after the date of the last event
4constituting the alleged violation for which the action is
5brought.

6(b) Posting requirements.--A hospital and other medical
7facility shall post the following provisions of this chapter in
8a prominent place for review by the public and the employees.
9The posting shall have a title across the top in no less than 35
10point, bold typeface stating the following: "RIGHTS OF
11REGISTERED NURSES AS PATIENT ADVOCATES, EMPLOYEES AND PATIENTS."

12Section 2. This act shall take effect in 60 days.