PRINTER'S NO. 1044
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
106
Session of
2023
INTRODUCED BY MEHAFFIE, TOMLINSON, KOSIEROWSKI, KHAN, CIRESI,
FIEDLER, FLEMING, HOGAN, HOHENSTEIN, ISAACSON, KIM, MATZIE,
NEILSON, PROBST, RABB, SANCHEZ, SMITH-WADE-EL, SOLOMON,
VENKAT, WARREN, MULLINS, DONAHUE, KRAJEWSKI, BENHAM, FREEMAN,
HARKINS, ZABEL, KINKEAD, ORTITAY, OTTEN, KENYATTA, GALLOWAY,
CEPEDA-FREYTIZ, McNEILL, GIRAL, O'MARA, WEBSTER, BOYLE,
BOROWSKI, KINSEY, T. DAVIS, HANBIDGE, YOUNG, RADER, STRUZZI,
ARMANINI, BRIGGS, LABS, CURRY, MUNROE, PASHINSKI, CERRATO,
WAXMAN, GREEN, PARKER, CONKLIN, STEELE, SIEGEL, KULIK,
BULLOCK, STURLA, SAPPEY, SHUSTERMAN, KAUFER, KRUEGER, GUENST,
DALEY, BRENNAN, BURGOS, MADDEN, FRIEL, MALAGARI, MAYES,
N. NELSON, D. MILLER, GALLAGHER, MERSKI, PISCIOTTANO,
BELLMON, SCOTT, DELLOSO, KAZEEM, ROZZI, HADDOCK, MADSEN,
C. WILLIAMS, CEPHAS, DEASY, ABNEY, WHITE, MARSHALL, GROVE,
FLICK, MAJOR, DELOZIER, MUSTELLO, SMITH, EMRICK, McANDREW,
D. WILLIAMS, SALISBURY, GERGELY, PIELLI, VITALI, MARKOSEK,
TAKAC, FRANKEL, INNAMORATO, HOWARD, SCHWEYER, HILL-EVANS,
SAMUELSON, DAWKINS AND GUZMAN, APRIL 28, 2023
REFERRED TO COMMITTEE ON HEALTH, APRIL 28, 2023
AN ACT
Amending the act of July 19, 1979 (P.L.130, No.48), entitled "An
act relating to health care; prescribing the powers and
duties of the Department of Health; establishing and
providing the powers and duties of the State Health
Coordinating Council, health systems agencies and Health Care
Policy Board in the Department of Health, and State Health
Facility Hearing Board in the Department of Justice;
providing for certification of need of health care providers
and prescribing penalties," providing for hospital patient
protection provisions; and imposing penalties.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The act of July 19, 1979 (P.L.130, No.48), known
as the Health Care Facilities Act, is amended by adding a
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chapter to read:
CHAPTER 8-C
HOSPITAL PATIENT PROTECTION PROVISIONS
Section 801-C. Definitions.
The following words and phrases when used in this chapter
shall have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Acuity." The measure of a patient's severity of illness or
medical conditions, including, but not limited to, the stability
of physiological and psychological parameters and the dependency
needs of the patient and the patient's family.
"Ancillary staff." Personnel employed by or contracted to
work at a facility who have an effect on the delivery of care to
patients. The term does not include physicians and registered
nurses.
"Charge nurse." A registered nurse responsible for the
management of a patient care unit.
"Department." The Department of Health of the Commonwealth.
"Direct care registered nurse." A registered nurse who is
engaged in direct patient care responsibilities in an inpatient
hospital unit setting for more than 50% of the registered
nurse's working hours.
"Direct care staff." Any of the following individuals who
are routinely assigned to patient care and are replaced when
they are absent:
(1) registered nurses;
(2) licensed practical nurses; or
(3) nursing assistants.
"Exclusive representative." A labor organization that is:
(1) certified as an exclusive representative by the
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National Labor Relations Board; or
(2) a party to a collective bargaining agreement.
"Hospital." An institution licensed by this act as a health
care facility and having an organized medical staff established
for the purpose of providing, by or under the supervision of
physicians or advanced practice nurses, diagnostic and
therapeutic services for the care of individuals who are
injured, disabled, pregnant, diseased, sick or mentally ill or
rehabilitation services for the rehabilitation of individuals
who are injured, disabled, pregnant, diseased, sick or mentally
ill. The term includes a private psychiatric hospital and public
psychiatric hospital as defined by 55 Pa. Code § 1151.2
(relating to definitions).
"Intensive care unit." A unit of a hospital that provides
care to critically ill patients who require advanced treatments
such as mechanical ventilation, vasoactive infusions or
continuous renal replacement treatment or who require frequent
assessment and monitoring.
"Intermediate care unit." A unit of a hospital that provides
progressive care, intensive specialty care or step-down care.
"Medical-surgical unit." An inpatient unit in which general
medical or post-surgical level of care is provided, excluding a
critical care unit and any unit referred to in sections 802-C,
803-C, 804-C and 805-C.
"Safe harbor." A process that protects a direct care
registered nurse from adverse action by the health care facility
where the direct care registered nurse accepts an assignment
despite objection over the ratios prescribed in section 802-C or
the staffing requirements prescribed by the staffing plan in
section 804-C.
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"Unit clerk." A worker on a nursing unit who schedules
patients for prescribed studies, prepares charts for patients,
answers the phone on the unit and handles other general clerical
tasks.
Section 802-C. Staffing ratios.
(a) General requirement.--A unit and criteria for patients
on units shall be consistent with the types of units and
patients contained in the Centers for Disease Control and
Prevention Locations and Descriptions and Instructions for
Mapping Patient Care Locations for types of hospital units.
(b) Direct care registered nurses.--A hospital nurse
staffing plan must ensure that at any given time:
(1) In an emergency department, a direct care registered
nurse is assigned to no more than four patients or no more
than one trauma patient.
(2) In an intensive care unit, a direct care registered
nurse is assigned to no more than two patients.
(3) In a labor and delivery unit, a direct care
registered nurse is assigned to no more than:
(i) two patients, if the patients are not in active
labor, experiencing complications or in immediate
postpartum;
(ii) one patient if:
(A) the patient is in active labor; or
(B) the patient is at any stage of labor and is
experiencing complications; or
(iii) one patient for the initiation of epidural
anesthesia and circulation for cesarean delivery.
(4) In a postpartum, antepartum and well-baby nursery, a
direct care registered nurse is assigned to no more than six
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patients, counting mother and baby each as separate patients.
(5) In an operating room, a direct care registered nurse
is assigned to no more than one patient.
(6) In an oncology unit, a direct care registered nurse
is assigned to no more than four patients.
(7) In a post-anesthesia care unit, a direct care
registered nurse is assigned to no more than two patients.
(8) In an intermediate care unit, a direct care
registered nurse is assigned to no more than three patients.
(9) In a medical-surgical unit, a direct care registered
nurse is assigned to no more than four patients.
(10) In a cardiac telemetry unit, a direct care
registered nurse is assigned to no more than three patients.
(11) In a pediatric unit, a direct care registered nurse
is assigned to no more than three patients.
(12) In a presurgical and admissions unit or ambulatory
surgical unit, a direct care registered nurse is assigned to
no more than four patients.
(13) In a burn unit, a direct care registered nurse is
assigned to no more than two patients.
(14) Any other specialty unit, a direct care registered
nurse is assigned to no more than four patients.
(15) In an in-patient psychiatric unit, a direct care
registered nurse is assigned to no more than four patients.
(16) In an in-patient rehabilitation unit, a direct care
registered nurse is assigned to no more than five patients.
(17) In an operating room, a direct care registered
nurse is assigned to no more than one patient.
(18) In a unit where a patient is receiving conscious
sedation, a direct care registered nurse is assigned to no
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more than one patient.
(c) Assignment of patients.--Patients must be assigned to
the appropriate unit to meet care needs.
(d) Minimums.--The direct care registered nurse ratios
specified in subsection (b) are the minimum required number of
nurses.
(e) Additional staff.--Additional registered nursing staff
in excess of the prescribed ratios in subsection (b) shall be
assigned to direct patient care in accordance with the patient's
acuity and care needs.
Section 803-C. Nurse staffing committee.
(a) Establishment.--
(1) A hospital shall establish a hospital nurse staffing
committee.
(2) The staffing committee shall:
(i) consist of hospital nurse managers and
registered nurse direct care staff;
(ii) include at least one direct care registered
nurse from each hospital nurse specialty or unit; and
(iii) include direct care registered nursing staff
who must comprise at least 50% of the total membership of
the committee.
(3) If any of the direct care registered nurses who work
at a hospital are represented under a collective bargaining
agreement, the exclusive representative shall select the
direct care registered nurse members of the committee.
(4) If the direct care registered nurses who work at a
hospital are not represented by an exclusive representative,
the direct care registered nurses belonging to a hospital
nurse specialty or unit shall elect each member of the
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committee from their peers through an anonymous process.
(b) Staffing plan.--A hospital nurse staffing committee
shall develop a written hospital-wide staffing plan for direct
care staff in accordance with this section and sections 802-C
and 804-C. The committee's primary goal in developing the
staffing plan shall be to ensure that the hospital is staffed to
meet the health care needs of patients. The committee shall
review and modify the staffing plan in accordance with this
section.
(c) Quorum.--A majority of the members of a hospital nurse
staffing committee constitutes a quorum for the transaction of
business.
(d) Cochairs to be elected.-- A hospital nurse staffing
committee must have two cochairs. One cochair must be a hospital
nurse manager elected by the members of the committee who are
hospital nurse managers and one cochair must be a direct care
registered nurse elected by the members of the committee who are
direct care staff.
(e) Voting.--A decision made by a hospital nurse staffing
committee must be made by a vote of a majority of the members of
the committee present at a meeting. If the members present at a
meeting consists of less than 50% direct care registered nurses,
the vote shall be held by a group of the members, who must be at
least 50% direct care registered nurses.
(f) Meetings.--A hospital nurse staffing committee shall
meet:
(1) At least once every three months.
(2) At any time and place specified by either cochair.
(g) Open meetings.--A hospital nurse staffing committee
meeting shall be open to:
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(1) The hospital direct care staff, as observers.
(2) Other observers or presenters, upon invitation by
either cochair.
(h) Excluded individuals.--At any time, either cochair may
exclude individuals described in subsection (g) from a committee
meeting for purposes related to deliberation and voting.
(i) Minutes.--The minutes of a hospital nurse staffing
committee meeting shall:
(1) Include motions made and outcomes of votes taken.
(2) Summarize discussions.
(3) Be posted online and in a physical location visible
to hospital staff in a timely manner.
(j) Release required.--A hospital shall release a member of
a hospital nurse staffing committee from the member's duties to
attend a committee meeting and provide paid leave.
Section 804-C. Staffing plans.
(a) Duty of hospital.--A hospital shall implement the
written hospital-wide staffing plan for nursing services that
meets the requirements of this chapter and that has been
developed and approved by the hospital nurse staffing committee.
(b) Requirements.--The staffing plan shall:
(1) Be based on the specialized qualifications and
competencies of the nursing staff and provide for the skill
mix and level of competency necessary to ensure that the
hospital is staffed to meet the health care needs of
patients.
(2) Be based on the size of the hospital and a
measurement of hospital unit activity that quantifies the
rate of admissions, discharges and transfers for each
hospital unit and the time required for a direct care
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registered nurse belonging to a hospital unit to complete
admissions, discharges and transfers for that hospital unit.
(3) Be based on total diagnoses for each hospital unit
and the nursing staff required to manage the set of diagnoses
and the unit's general and predominant patient population as
defined by the Medicare severity diagnosis-related groups
adopted by the Centers for Medicare and Medicaid Services, or
by other measures for patients who are not classified in the
Medicare severity diagnosis-related groups.
(4) Be consistent with any nationally recognized
evidence-based standards and guidelines established by
professional nursing specialty organizations and
credentialing bodies.
(5) Recognize differences in patient acuity.
(6) Recognize the availability of ancillary staff
support on the unit.
(7) Provide for additional registered nursing staff in
excess of the prescribed staffing ratios in section 802-C
when necessary, based on patient acuity and nursing care
requirements.
(8) Establish a minimum number of additional direct care
staff, unit clerks and charge nurses required on specified
shifts, provided that at least one direct care registered
nurse and one other nonregistered nurse direct care staff is
on duty in a unit when a patient is present. Additional
direct care staff requirements shall be based on the direct
care staff needs of individual patients, and patient nursing
care requirements and shall provide for shift-by-shift
staffing for each unit.
(9) Not base nursing staff requirements solely on
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external benchmarking data.
(10) Comply with section 802-C.
Section 805-C. Staffing transparency.
(a) Duty of hospital.--A hospital shall maintain and post,
in a physical location in each unit and a publicly accessible
Internet website:
(1) A list of on-call nursing staff or staffing agencies
to provide replacement nursing staff in the event of a
vacancy. The list of on-call nursing staff or staffing
agencies shall be sufficient to provide for replacement
nursing staff.
(2) Staffing requirements, as determined by the staffing
plan for each unit, on a day-to-day, shift-by-shift basis.
(3) The actual staff and staff mix provided for each
unit, on a day-to-day, shift-by-shift basis.
(4) The variance between required and actual staffing
patterns, on a day-to-day, shift-by-shift basis.
(b) When notice of changes required.--If any of the direct
care staff who work at a hospital are represented under a
collective bargaining agreement, the hospital may not change the
direct care staff's wages, hours or other terms and conditions
of employment under the staffing plan unless the hospital first
provides notice to and, upon request, bargains with the direct
care staff in the bargaining unit and their exclusive
representative.
(c) Relationship of staffing plan to collective bargaining
agreement.--A staffing plan does not create, preempt or modify a
collective bargaining agreement or require a union or hospital
to bargain over the staffing plan while a collective bargaining
agreement is in effect.
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(d) Submission of staffing plan to department.--A hospital
shall submit to the department a staffing plan adopted in
accordance with this section and submit any change to the plan
no later than 30 days after approval of the changes by the
hospital nurse staffing committee.
Section 806-C. Review of staffing plan.
(a) Duty of hospital nurse staffing committee.--A hospital
nurse staffing committee established in section 803-C shall
review the written hospital-wide staffing plan:
(1) At least once every year.
(2) At any other date and time specified by either
cochair of the committee.
(b) Matters to be reviewed.--In reviewing a staffing plan, a
hospital nurse staffing committee shall consider:
(1) Patient outcomes, including nursing quality
indicators.
(2) Complaints regarding staffing and reports of safe
harbor, including complaints about a delay in direct care
nursing or an absence of direct care nursing.
(3) The number of hours of nursing care provided through
a hospital unit compared with the number of patients served
by the hospital unit during a 24-hour period.
(4) The aggregate hours of mandatory overtime worked by
the nursing staff.
(5) The aggregate hours of voluntary overtime worked by
the nursing staff.
(6) The percentage of shifts for each hospital unit for
which staffing differed from what is required by the staffing
plan.
(7) Any other matter determined by the committee to be
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necessary to ensure that the hospital is staffed to meet the
health care needs of patients.
(c) Outcome of review.--Upon conclusion of its review of a
staffing plan, a hospital nurse staffing committee shall:
(1) Report whether the staffing plan ensures that the
hospital is staffed to meet the health care needs of
patients.
(2) Modify the staffing plan as necessary to ensure that
the hospital is staffed to meet the health care needs of
patients.
Section 807-C. Safe harbor provisions.
(a) Duty of department.--The department shall develop a form
to be used by direct care registered nurses invoking safe
harbor. The form shall include the following information:
(1) The name and signature of the direct care registered
nurse making the request.
(2) The date and time of the request.
(3) The location where the conduct or assignment that is
the subject of the request occurred.
(4) The name of the individual who requested the direct
care registered nurse to engage in the conduct or made the
assignment that is the subject of the request.
(5) The name of the supervisor recording the request, if
applicable.
(6) An explanation of why the direct care registered
nurse is requesting safe harbor.
(7) A description of the collaboration between the
direct care registered nurse and the supervisor, if
applicable.
(b) Time period for suspension of form.--The direct care
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registered nurse invoking safe harbor must submit the form
within 24 hours of the incident cited.
(c) Duty of facility to retain copy of form.--The facility
of the direct care registered nurse invoking safe harbor must
retain a copy of the request for safe harbor.
(d) Prohibited conduct.--A hospital may not discharge from
duty or otherwise retaliate against an employee for invoking
safe harbor or filing a complaint for violations of this
chapter.
Section 808-C. Enforcement.
(a) Duties of department.--The department shall:
(1) Establish a method by which a complaint may be filed
along with supporting documentation through the department's
publicly accessible Internet website regarding a violation
listed in section 807-C.
(2) No later than 30 days after receiving a complaint of
a violation listed in section 807-C, open an investigation of
the hospital and provide a notice of the investigation to the
complainant, the hospital and the cochairs of the nurse
staffing committee established under section 803-C, and to
the exclusive representative, if any, of the employee filing
the complaint. The notice shall include a summary of the
complaint but not the complainant's name or the specific
date, shift or unit, and the calendar week in which the
complaint arose.
(3) Conclude the investigation no later than 60 days
after opening the investigation. The department shall provide
a written report on the complaint to the cochairs of the
hospital staffing committee and the exclusive representative
if any, of the complainant. The report:
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(i) Shall include a summary of the complaint.
(ii) Shall include the nature of the alleged
violation or violations.
(iii) Shall include the department's findings and
factual bases for the findings.
(iv) Shall include other information the department
determines is appropriate to include in the report.
(v) May not include the name of any complainant who
is a patient or the name of any individual that the
department interviewed in investigating the complaint.
(vi) Shall, if the department imposes one or more
civil penalties, include a notice of the civil penalties
that complies with this chapter.
(4) In conducting an investigation, make on-site
inspections of the unit, conduct interviews, compel the
production of documents and records pertaining to the
complaint and take any other steps deemed necessary to
investigate the complaint.
(b) Time period for filing complaints.--A complaint must be
filed no later than 60 days after the date of the violation
alleged in the complaint. The department may not investigate a
complaint or take enforcement action with respect to a complaint
that has not been filed in accordance with this chapter.
Section 809-C. Violations and right to issue penalties.
(a) Duty of department.--The department shall impose civil
penalties or suspend or revoke a license of a hospital for a
violation of any provision of this chapter. The department shall
adopt by rule a schedule establishing the amount of civil
penalty that may be imposed for a violation as described in this
section when there is a reasonable belief that safe patient care
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has been or may be negatively impacted, except that a civil
penalty may not exceed $15,000 per violation.
(b) Separate violations.--Each violation of a written
hospital-wide staffing plan shall be considered a separate
violation, and there is no cap on the times that a penalty may
be imposed for a repeat of a violation.
(c) Evidence that may be considered.--In determining whether
to impose a civil penalty, the department shall consider all
relevant evidence, including, but not limited to, witness
testimony, written documents and the observations of the
investigator.
(d) Penalties.--Following the receipt of a complaint and
completion of an investigation described in section 808-C for a
violation described in subsection (b), the department shall:
(1) Issue a warning for the first violation.
(2) Impose a civil penalty of $7,500 for a second
violation of the same provision.
(3) Impose a civil penalty of $15,000 for each third and
subsequent violation of the same provision.
(e) Other penalties.--
(1) The department shall take the actions described in
subsection (a) for any violation of this chapter, including,
but not limited to, the following:
(i) Failure to establish a nurse staffing committee.
(ii) Failure to adopt a staffing plan in a timely
manner.
(iii) Failure to comply with the staffing level in
the staffing plan, including the nurse-to-patient
staffing ratios prescribed in section 802-C, if
applicable.
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(2) If a direct care registered nurse at a hospital is
unable to attend a staffing committee meeting because the
direct care registered nurse was not released from other
hospital duties to attend the committee, in violation of
section 803-C, the department shall:
(i) Issue a warning for the first violation.
(ii) Impose a civil penalty of up to $1,500 for a
second and each subsequent violation.
(iii) Maintain for public inspection records of any
civil penalties or license suspensions or revocations
imposed on hospitals penalized under this chapter.
Section 810-C. Public posting.
The department shall post on a publicly accessible Internet
website maintained by the department:
(1) The hospital staffing plans received by the
department.
(2) Any report, described in section 806-C, made
pursuant to an investigation of a complaint for which the
department issued a warning or imposed a civil penalty under
sections 807-C and 808-C.
(3) Any order requiring a hospital to remedy a violation
as described in section 808-C.
(4) Any order imposing a civil penalty against a
hospital or suspending or revoking the license of a hospital
pursuant to the violations as described in section 808-C.
Section 811-C. Emergency declarations.
(a) Duty of hospital nurse staffing committee.--Upon the
occurrence of an emergency declaration either cochair of the
hospital nurse staffing committee may require the hospital nurse
staffing committee to meet to review and potentially modify the
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staffing plan in response to the emergency declaration or
circumstances.
(b) Duties of hospital.--
(1) If an emergency causes a significant and atypical
change in the number of patients on a unit, the hospital
shall demonstrate that immediate and diligent efforts were
made to maintain required staffing levels.
(2) No later than 30 days after a hospital deviates from
a written hospital-wide staffing plan under section 804-C,
the hospital incident command shall report an assessment of
the nurse staffing needs arising from the emergency
declaration to the cochairs of the hospital nurse staffing
committee established under section 803-C.
(c) Limitations.--
(1) The hospital's deviation from the written hospital-
wide staffing plan under subsection (b) may not be in effect
for more than 90 days without the approval of the hospital
nurse staffing committee.
(2) Any contingency staffing plans or modified staffing
plans will terminate when the Federal Government or the head
of a State, local, county or municipal government ends the
emergency declaration.
(d) Definitions.--As used in this section, the following
words and phrases shall have the meanings given to them in this
subsection unless the context clearly indicates otherwise:
"Emergency." An event declared an emergency by the Federal
Government or the head of a State, local, county or municipal
government.
Section 812-C. Implementation.
The department may adopt regulations necessary to carry out
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this chapter.
Section 2. This act shall take effect in six months.
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