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PRIOR PRINTER'S NOS. 1044, 1462
PRINTER'S NO. 1743
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,
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, 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, CEPHAS, DEASY, ABNEY, WHITE,
MARSHALL, FLICK, MAJOR, DELOZIER, EMRICK, McANDREW,
D. WILLIAMS, SALISBURY, GERGELY, PIELLI, VITALI, MARKOSEK,
TAKAC, FRANKEL, INNAMORATO, HOWARD, SCHWEYER, HILL-EVANS,
SAMUELSON, DAWKINS, GUZMAN AND RYNCAVAGE, APRIL 28, 2023
AS AMENDED ON SECOND CONSIDERATION, HOUSE OF REPRESENTATIVES,
JUNE 27, 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.
"HIGH MEDICAL ASSISTANCE HOSPITAL." A HOSPITAL AS DETERMINED
UNDER THE MEDICAL ASSISTANCE DEPENDENCY PAYMENT PROVISIONS OF
THE COMMONWEALTH'S APPROVED TITLE XIX STATE PLAN, BASED ON A
HOSPITAL'S APPROVED MEDICAL ASSISTANCE COST REPORT FOR FISCAL
YEAR 2018-2019.
"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, 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 ยง 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 and 804-C .
"RURAL HOSPITAL." AS DEFINED IN SECTION 103 OF THE ACT OF
NOVEMBER 27, 2019 (P.L.742, NO.108), KNOWN AS THE PENNSYLVANIA
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RURAL HEALTH REDESIGN CENTER AUTHORITY ACT.
"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 803-C .
"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 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:
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(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
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
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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
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 patients'
acuity and care needs.
Section 803-C . Staffing plans.
(a) Duty of hospital.--A hospital shall develop a written
hospital-wide staffing plan for direct care and other ancillary
staff in accordance with this section and section 802-C. The
hospital'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. A hospital shall implement the written
hospital-wide staffing plan for nursing services that meets the
requirements of this chapter.
(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
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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
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
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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. The staffing plan shall ensure that
the hospital implements the requirements without diminishing
the staffing levels of its ancillary staff.
(9) Not base nursing staff requirements solely on
external benchmarking data.
(10) Comply with section 802-C.
Section 804-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
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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.
(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.
Section 805-C . Review of staffing plan.
(a) Duty of hospital.--A hospital shall review the written
hospital-wide staffing plan at least once every year.
(b) Matters to be reviewed.--In reviewing a staffing plan, a
hospital 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.
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(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 hospital to be
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 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 806-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.
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(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
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 807-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 of
this chapter .
(2) No later than 30 days after receiving a complaint of
a violation of this chapter , open an investigation of the
hospital and provide a notice of the investigation to the
complainant, the hospital 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 complainant and the
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exclusive representative if any, of the complainant. The
report:
(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 808-C. Violations and right to issue penalties.
(A) IMPOSITION.-- The department may impose civil and
administrative penalties to ensure compliance with this chapter,
including, but not limited to:
(1) Corrective action plans.
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(2) Civil penalties.
(3) Declaration of immediate jeopardy.
(4) Suspension or revocation of a hospital license.
Penalties shall increase in severity for repeat violations. The
department shall adopt by rule a schedule establishing the
amount of civil penalty that may be imposed for a violation,
except that a civil penalty may be no less than $2,000 per
violation.
(B) AMOUNT.--PENALTIES SHALL INCREASE IN SEVERITY FOR REPEAT
VIOLATIONS. THE DEPARTMENT SHALL ADOPT BY RULE A SCHEDULE
ESTABLISHING THE AMOUNT OF CIVIL PENALTY THAT MAY BE IMPOSED FOR
A VIOLATION, EXCEPT THAT A CIVIL PENALTY MAY BE NO LESS THAN
$1,000 AND NO MORE THAN $2,500 PER VIOLATION.
(C) GRANT.--MONEY COLLECTED BY THE DEPARTMENT UNDER THIS
SECTION SHALL BE USED TO ESTABLISH A GRANT PROGRAM WITHIN THE
DEPARTMENT FOR THE PURPOSE OF RECRUITMENT AND RETENTION OF
REGISTERED NURSES. GRANTS MAY ONLY BE AWARDED TO RURAL HOSPITALS
AND HIGH MEDICAL ASSISTANCE HOSPITALS. THE DEPARTMENT SHALL
DEVELOP AN APPLICATION FORM AND SHALL POST THE FORM
ELECTRONICALLY ON THE DEPARTMENT'S PUBLICLY ACCESSIBLE INTERNET
WEBSITE.
(D) APPLICABILITY.--
(1) EXCEPT AS PROVIDED UNDER PARAGRAPH (2), THIS SECTION
SHALL NOT APPLY TO HOSPITALS UNTIL ONE YEAR AFTER THE
EFFECTIVE DATE OF THIS SECTION.
(2) THIS SECTION SHALL NOT APPLY TO RURAL HOSPITALS OR
HIGH MEDICAL ASSISTANCE HOSPITALS UNTIL TWO YEARS AFTER THE
EFFECTIVE DATE OF THIS SECTION.
Section 809-C . Public posting.
The department shall post on a publicly accessible Internet
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website maintained by the department:
(1) The hospital staffing plans received by the
department.
(2) Any report, described in section 807-C , made
pursuant to an investigation of a complaint for which the
department issued a warning or imposed a civil or
administrative penalty under sections 807-C and 808-C.
(3) Any order requiring a hospital to remedy a violation
as described in section 807-C .
(4) The department shall maintain for public inspection
and make publicly available records of civil or
administrative penalties, including license suspensions,
revocations, corrective action plans or other enforcement
actions imposed on hospitals that violate this chapter.
Section 810-C . Emergency declarations.
(a) Duties of hospital.--If an emergency causes a
significant and atypical change in the number of patients on a
unit BEYOND NORMAL FLUCTUATIONS IN A CENSUS, INCLUDING, BUT NOT
LIMITED TO, A MASS CASUALTY EVENT OR A GOVERNMENT-DECLARED
EMERGENCY BY THE FEDERAL, STATE, COUNTY OR MUNICIPAL GOVERNMENT ,
the hospital shall demonstrate that immediate and diligent
efforts were made to maintain required staffing levels. The
hospital must maintain such diligent efforts to meet the
requirements of this chapter for the full duration of the
emergency.
(b) 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
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government. (RESERVED).
Section 811-C . Implementation.
The department may adopt regulations necessary to carry out
this chapter.
Section 2. This act shall take effect in six months ONE
YEAR.
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