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.

21The General Assembly finds that:

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

4(2) Competent, safe, therapeutic and effective patient
5care is jeopardized because of staffing changes implemented
6in response to market-driven managed care.

7(3) To ensure effective protection of patients in acute
8care settings, it is essential that qualified direct care
9registered nurses be accessible and available to meet the
10individual needs of patients at all times.

11(4) To ensure the health and welfare of Pennsylvania
12citizens, mandatory hospital direct care professional nursing
13practice standards and professional practice protections must
14be established to assure that hospital nursing care is
15provided in the exclusive interests of patients.

16(5) Direct care registered nurses have a fiduciary duty
17to assigned patients and necessary duty and right of patient
18advocacy and collective patient advocacy to satisfy
19professional fiduciary obligations.

20(6) The basic principles of staffing in hospital
21settings should be based on the individual patient's care
22needs, the severity of the condition, services needed and the
23complexity surrounding those services.

24(7) Current unsafe hospital direct care registered nurse
25staffing practices have resulted in adverse patient outcome.

26(8) Mandating adoption of uniform, minimum, numerical
27and specific registered nurse-to-patient staffing ratios by
28licensed hospital facilities is necessary for competent,
29safe, therapeutic and effective professional nursing care and
30for retention and recruitment of qualified direct care

1registered nurses.

2(9) Direct care registered nurses must be able to
3advocate for their patients without fear of retaliation from
4their employer.

5(10) Whistleblower protections that encourage registered
6nurses and patients to notify government and private
7accreditation entities of suspected unsafe patient
8conditions, including protection against retaliation for
9refusing unsafe patient care assignments by competent
10registered nurse staff, will greatly enhance the health,
11welfare and safety of patients.

12Section 833-A. Definitions.

13The following words and phrases when used in this chapter
14shall have the meaning given to them in this section unless the
15context clearly indicates otherwise:

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

20(1) The severity of patient illness.

21(2) The need for specialized equipment and technology.

22(3) The intensity of required nursing interventions.

23(4) The complexity of clinical nursing judgment required
24to design, implement and evaluate the patient's nursing care
25plan consistent with professional standards.

26(5) The ability for self-care, including motor, sensory
27and cognitive deficits.

28(6) The need for advocacy intervention.

29(7) The licensure of the personnel required for care.

30(8) The patient care delivery system.

1(9) The unit's geographic layout.

2(10) Generally accepted standards of nursing practice,
3as well as elements reflective of the unique nature of the
4acute care hospital's patient population.

5The system determines the additional number of direct care
6registered nurses and other licensed and unlicensed nursing
7staff the hospital must assign, based on the independent
8professional judgment of the direct care registered nurse, to
9meet the individual patient needs at all times.

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

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

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

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

27(1) The statutorily recognized duties and
28responsibilities of the registered nurses as provided under
29the laws of this Commonwealth.

30(2) The standards required under this chapter that are

1specific to each hospital unit.

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

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

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

19(1) Is currently licensed by the Pennsylvania Board of
20Nursing to engage in professional nursing with documented
21clinical competence as defined in the act of May 22, 1951
22(P.L.317, No.69), known as The Professional Nursing Law.

23(2) Has accepted a direct, hands-on patient care
24assignment to implement medical and nursing regimens and
25provide related clinical supervision of patient care while
26exercising independent professional judgment at all times in
27the interests of a patient.

28"Hospital." An entity located in this Commonwealth that is
29licensed as a hospital under this act. The term includes a
30critical access and long-term acute care hospital.

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

9"Long-term acute care hospital." A hospital or health care
10facility that specializes in providing acute care to medically
11complex patients with an anticipated length of stay of more than
1225 days. The term includes a free-standing and a hospital-
13within-hospital model of a long-term acute care facility.

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

15(1) Is established to safeguard and protect patients
16whose severity of illness, including all comorbidities,
17restorative measures and level of nursing intensity requires
18continuous care through direct observation by a direct care
19registered nurse, monitoring, multiple assessments,
20specialized interventions, evaluations and the education or
21teaching of a patient's family or other representatives by a
22competent and experienced direct care registered nurse.

23(2) May include patients requiring less than intensive
24care or step-down care and patients receiving 24-hour
25inpatient general medical care, postsurgical care or both.

26(3) May include mixed patient populations of diverse
27diagnoses and diverse age groups, excluding pediatric
28patients.

29"Patient assessment." The direct care utilization by a
30registered nurse of critical thinking, which is the

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

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

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

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

18(1) Provides skilled nursing care and supportive care to
19patients whose primary need is for the availability of
20skilled nursing care on a long-term basis and who are
21admitted after at least a 48-hour period of continuous
22inpatient care.

23(2) Provides at least the following:

24(i) medical;

25(ii) nursing;

26(iii) dietary;

27(iv) pharmaceutical services; and

28(v) an activity program.

29"Specialty care unit." A unit that:

30(1) Is established to safeguard and protect patients

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

8(2) Provides intensity of care for a specific medical
9condition or a specific patient population.

10(3) Is more comprehensive for the specific condition or
11disease process than that which is required on a
12medical/surgical unit and is not otherwise covered by the
13definitions in this section.

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

15(1) To safeguard and protect patients whose severity of
16illness, including all comorbidities, restorative measures
17and level of nursing intensity requires intermediate
18intensive care through direct observation by the direct care
19registered nurse, monitoring, multiple assessments,
20specialized interventions, evaluations and the education and
21teaching of the patient's family or other representatives by
22a competent and experienced direct care registered nurse.

23(2) To provide care to patients with moderate or
24potentially severe physiologic instability requiring
25technical support but not necessarily artificial life
26support.

27"Technical support." Specialized equipment and direct care
28registered nurses providing for invasive monitoring, telemetry
29and mechanical ventilation for the immediate amelioration or
30remediation of severe pathology for those patients requiring

1less care than intensive care, but more care than that which is
2required from medical/surgical care.

3"Telemetry unit." A unit that:

4(1) Is established to safeguard and protect patients
5whose severity of illness, including all comorbidities,
6restorative measures and level of nursing intensity requires
7intermediate intensive care through direct observation by a
8direct registered nurse, monitoring, multiple assessments,
9specialized interventions, evaluations and the education and
10teaching of a patient's family or other representatives by a
11competent and experienced direct care registered nurse.

12(2) Is designated for the electronic monitoring,
13recording, retrieval and display of cardiac electrical
14signals.

15Section 834-A. Hospital nursing practice standard.

16(a) Professional obligation and right.--By virtue of their
17professional license and ethical obligations, all registered
18nurses have a duty and right to act and provide care in the
19exclusive interests of a patient and to act as the patient's
20advocate, as circumstances require, in accordance with the
21provisions described in section 836-A.

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

23(1) A direct care registered nurse shall provide
24competent, safe, therapeutic and effective nursing care to
25assigned patients.

26(2) As a condition of licensure, a health care facility
27shall adopt, disseminate to direct care nurses and comply
28with a written policy that details the circumstances under
29which a direct care nurse may refuse a work assignment.

30(3) At a minimum, the policy shall permit a direct care

1nurse to refuse a patient assignment for which:

2(i) the nurse does not have the necessary knowledge,
3judgment, skills and ability to provide the required care
4without compromising or jeopardizing the patient's
5safety, the nurse's ability to meet foreseeable patient
6needs or the nurse's license; and

7(ii) the assignment otherwise would violate
8requirements under this chapter.

9(4) At a minimum, the policy shall permit a direct care
10nurse to assess an order initiated by a physician or legally
11authorized health care professional before implementation to
12determine if the order is:

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

14(ii) initiated by a person legally authorized to
15issue the order; and

16(iii) in accordance with applicable law and
17regulation governing nursing care.

18(5) At a minimum, the work assignment policy shall
19contain procedures for the following:

20(i) Reasonable requirements for prior notice to the
21nurse's supervisor regarding the nurse's request and
22supporting reasons for being relieved of the assignment,
23continued duty or implementation of an order.

24(ii) Where feasible, an opportunity for the
25supervisor to review the specific conditions supporting
26the nurse's request and to decide whether to:

27(A) remedy the conditions;

28(B) to relieve the nurse of the assignment or
29order; or

30(C) deny the nurse's request to be relieved of

1the assignment, continued duty or implementation of
2an order.

3(iii) A process that permits the nurse to exercise
4the right to refuse the assignment, continued on-duty
5status or implementation of an order when the supervisor
6denies the request to be relieved if:

7(A) The supervisor rejects the request without
8proposing a remedy or the proposed remedy would be
9inadequate or untimely.

10(B) The complaint and investigation process with
11a regulatory agency would be untimely to address
12concern.

13(C) The employee, in good faith, believes that
14the assignment or implementation of an order meets
15conditions justifying refusal.

16(iv) A nurse who refuses an assignment or
17implementation of an order under a work assignment policy
18established in this section shall not be deemed, by
19reason thereof, to have engaged in negligent or
20incompetent action, patient abandonment or otherwise to
21have violated applicable nursing law.

22Section 835-A. Professional duty and right of patient advocacy.

23A registered nurse has the professional obligation, and
24therefore the right, to act as a patient's advocate as
25circumstances require by:

26(1) initiating action to improve health care or to
27change decisions or activities which in the professional
28judgment of the direct care registered nurse are against the
29interests or wishes of the patient; or

30(2) giving the patient the opportunity to make informed

1decisions about health care before it is provided.

2Section 836-A. Free speech.

3(a) Prohibition against discharge or retaliation for
4whistleblowing.--A hospital or other health care facility may
5not discharge from duty or otherwise retaliate against a direct
6care registered nurse or other health care professional
7responsible for patient care who reports unsafe practices or
8violation of policy, regulation, rule or law.

9(b) Rights guaranteed as essential to effective patient
10advocacy.--

11(1) A direct care registered nurse or other health care
12professional or worker responsible for patient care in a
13hospital shall enjoy the right of free speech and shall be
14protected in the exercise of that right as provided in this
15section, both during working hours and during off-duty hours.

16(2) The right of free speech protected by this section
17is a necessary incident of the professional nurse duty of
18patient advocacy and is essential to protecting the health
19and safety of hospital patients and of the people of this
20Commonwealth.

21(c) Protected speech.--

22(1) The "free speech" protected by this section
23includes, without limitation, any type of spoken, gestured,
24written, printed or electronically communicated expression
25concerning any matter related to or affecting competent,
26safe, therapeutic and effective nursing care by direct care
27registered nurses or other health care professionals and
28workers at the hospital facility, at facilities within large
29health delivery systems or corporate chains that include the
30hospital, or more generally within the health care industry.

1(2) The content of speech protected by this section
2includes, without limitation, the facts and circumstances of
3particular events, patient care practices, institutional
4actions, policies or conditions that may facilitate or impede
5competent, safe, therapeutic and effective nursing practice
6and patient care, adverse patient outcomes or incidents,
7sentinel and reportable events and arguments in support of or
8against hospital policies or practices relating to the
9delivery of nursing care.

10(3) Protected speech under this section includes the
11reporting, internally, externally or publicly, of actions,
12conduct, events, practices or other matters that are believed
13to constitute:

14(i) a violation of Federal, State or local laws or
15regulations;

16(ii) a breach of applicable codes of professional
17ethics, including the professional and ethical
18obligations of direct care registered nurses;

19(iii) matters which, in the independent judgment of
20the reporting direct care registered nurse, are
21appropriate or required for disclosure in furtherance and
22support of the nurse's exercise of patient advocacy
23duties to improve health care or change decisions or
24activities which, in the professional judgment of the
25direct care registered nurse, are against the interests
26or wishes of the patient or to ensure that the patient is
27afforded a meaningful opportunity to make informed
28decisions about health care before it is provided; or

29(iv) concern matters as described in subparagraph
30(iii) made in aid and support of the exercise of patient

1advocacy duties of direct care registered nurse
2colleagues.

3(d) Nondisclosure of confidential information.--Nothing in
4this section shall be construed to authorize disclosure of
5private and confidential patient information except where the
6disclosure is:

7(1) required by law;

8(2) compelled by proper legal process;

9(3) consented to by the patient; or

10(4) provided in confidence to regulatory or
11accreditation agencies or other government entities for
12investigatory purposes or under formal or informal complaints
13of unlawful or improper practices for purposes of achieving
14corrective and remedial action.

15(e) Duty of patient advocacy.--Engaging in free speech
16activity as described in this section constitutes an exercise of
17the direct care registered nurse's duty and right of patient
18advocacy. The subject matter of free speech activity as
19described in this section is presumed to be a matter of public
20concern, and the disclosures protected under this section are
21presumed to be in the public interest.

22Section 837-A. Protected rights.

23(a) General rule.--A person shall have the right to:

24(1) oppose policies, practices or actions of a hospital
25or other medical facility that are alleged to violate, breach
26or fail to comply with any provision of this chapter; and

27(2) cooperate, provide evidence, testify or otherwise
28support or participate in any investigation or complaint
29proceeding under sections 845-A and 846-A.

30(b) Right to file complaint.--

1(1) A patient of a hospital or other medical facility
2aggrieved by the hospital's or facility's interference with
3the full and free exercise of patient advocacy duties by a
4direct care registered nurse shall have the right to make or
5file a complaint, cooperate, provide evidence, testify or
6otherwise support or participate in any investigation or
7complaint proceeding under sections 845-A and 846-A.

8(2) A direct care registered nurse of a hospital or
9other medical facility aggrieved by the hospital's or
10facility's interference with the full and free exercise of
11patient advocacy duties shall have the right to make or file
12a complaint, cooperate, provide evidence, testify or
13otherwise support or participate in any investigation or
14complaint proceeding under sections 845-A and 846-A.

15Section 838-A. Interference with rights and duties of free
16speech and patient advocacy prohibited.

17No hospital or other medical facility employer or its agents
18may:

19(1) interfere with, restrain, coerce, intimidate or deny
20the exercise of or the attempt to exercise, by a person of a
21right provided or protected under this chapter; or

22(2) discriminate or retaliate against a person for
23opposing a policy, practice or action of the hospital or
24other medical facility which is alleged to violate, breach or
25fail to comply with any provisions of this chapter.

26Section 839-A. No retaliation or discrimination for protected
27actions.

28No hospital or other medical facility employer may
29discriminate or retaliate in any manner against a patient,
30employee or contract employee of the hospital or other medical

1facility or any other person because that person has:

2(1) presented a grievance or complaint or has initiated
3or cooperated in an investigation or proceeding of a
4governmental entity, regulatory agency or private
5accreditation body; or

6(2) made a civil claim or demand or filed an action
7relating to the care, services or conditions of the hospital
8or of any affiliated or related facilities.

9Section 840-A. Direct care registered nurse-to-patient staffing
10ratios.

11(a) General requirements.--A hospital shall provide minimum
12staffing by direct care registered nurses in accordance with the
13general requirements of this subsection and the clinical unit or
14clinical patient care area direct care registered nurse-to-
15patient ratios specified in subsection (b). Staffing for patient
16care tasks not requiring a direct care registered nurse is not
17included within these ratios and shall be determined under an
18acuity-based patient classification system, this section and
19section 841-A. The requirements are as follows:

20(1) No hospital may assign a direct care registered
21nurse to a nursing unit or clinical area unless that hospital
22and the direct care registered nurse determine that the
23direct care registered nurse has demonstrated and validated
24current competence in providing care in that area and has
25also received orientation to that hospital's clinical area
26sufficient to provide competent, safe, therapeutic and
27effective care to patients in that area. The policies and
28procedures of the hospital shall contain the hospital's
29criteria for making this determination.

30(2) (i) Direct care registered nurse-to-patient ratios

1represent the maximum number of patients that shall be
2assigned to one direct care registered nurse at all
3times.

4(ii) For purposes of this paragraph, "assigned"
5means the direct care registered nurse has responsibility
6for the provision of care to a particular patient within
7the direct care registered nurse's validated competency.

8(3) There shall be no averaging of the number of
9patients and the total number of direct care registered
10nurses on the unit during any one shift nor over any period
11of time.

12(4) Only direct care registered nurses providing direct
13patient care shall be included in the ratios. Nurse
14administrators, nurse supervisors, nurse managers, charge
15nurses and case managers may not be included in the
16calculation of the direct care registered nurse-to-patient
17ratio. Only direct care registered nurses shall relieve other
18direct care registered nurses during breaks, meals and other
19routine, expected absences from the unit.

20(5) Only direct care registered nurses shall be assigned
21to intensive care newborn nursery service units, which
22specifically require one direct care registered nurse to two
23or fewer infants at all times.

24(6) In the emergency department, only direct care
25registered nurses shall be assigned to triage patients, and
26only direct care registered nurses shall be assigned to
27critical trauma patients.

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

29(1) The minimum staffing ratios for general, acute,
30critical access and specialty hospitals are established in

1this subsection for direct care registered nurses as follows:

2(i) The direct care registered nurse-to-patient
3ratio in an intensive care unit shall be 1:2 or fewer at
4all times.

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

8(iii) The direct care registered nurse-to-patient
9ratio for a neonatal intensive care unit shall be 1:2 or
10fewer at all times.

11(iv) The direct care registered nurse-to-patient
12ratio for a burn unit shall be 1:2 or fewer at all times.

13(v) The direct care registered nurse-to-patient
14ratio for a step-down, intermediate care unit shall be
151:3 or fewer at all times.

16(vi) An operating room shall have at least one
17direct care registered nurse assigned to the duties of
18the circulating registered nurse and a minimum of one
19additional person as a scrub assistant for each patient-
20occupied operating room.

21(vii) The direct care registered nurse-to-patient
22ratio in the postanesthesia recovery unit of an
23anesthesia service shall be 1:2 or fewer at all times,
24regardless of the type of anesthesia the patient
25received.

26(viii) The direct care registered nurse-to-patient
27ratio for patients receiving conscious sedation shall be
281:1 at all times.

29(ix) (A) The direct care registered nurse-to-
30patient ratio for an emergency department shall be

11:4 or fewer at all times.

2(B) The direct care registered nurse-to-patient
3ratio for critical care patients in the emergency
4department shall be 1:2 or fewer at all times.

5(C) Only direct care registered nurses shall be
6assigned to critical trauma patients in the emergency
7department, and a minimum direct care registered
8nurse-to-critical trauma patient ratio of 1:1 shall
9be maintained at all times.

10(D) In an emergency department, triage, radio or
11specialty/flight, registered nurses do not count in
12the calculation of direct care registered nurse-to-
13patient ratio.

14(x) (A) The direct care registered nurse-to-patient
15ratio in the labor and delivery suite of prenatal
16services shall be 1:1 at all times for active labor
17patients and patients with medical or obstetrical
18complications.

19(B) The direct care registered nurse-to-patient
20ratio shall be 1:1 at all times for initiating
21epidural anesthesia and circulation for cesarean
22delivery.

23(C) The direct care registered nurse-to-patient
24ratio for patients in immediate postpartum shall be
251:2 or fewer at all times.

26(xi) (A) The direct care registered nurse-to-
27patient ratio for antepartum patients who are not in
28active labor shall be 1:3 or fewer at all times.

29(B) The direct care registered nurse-to-patient
30ratio for patients in a postpartum area of the

1prenatal service shall be 1:3 mother-baby couplets or
2fewer at all times.

3(C) In the event of cesarean delivery, the total
4number of mothers plus infants assigned to a single
5direct care registered nurse shall never exceed four.

6(D) In the event of multiple births, the total
7number of mothers plus infants assigned to a single
8direct care registered nurse shall not exceed six.

9(E) For postpartum areas in which the direct
10care registered nurse's assignment consists of
11mothers only, the direct care registered nurse-to-
12patient ratio shall be 1:4 or fewer at all times.

13(F) The direct care registered nurse-to-patient
14ratio for postpartum women or postsurgical
15gynecological patients shall be 1:4 or fewer at all
16times.

17(G) Well baby nursery direct care registered
18nurse-to-patient ratio shall be 1:5 or fewer at all
19times.

20(H) The direct care registered nurse-to-patient
21ratio for unstable newborns and those in the
22resuscitation period as assessed by the direct care
23registered nurse shall be 1:1 at all times.

24(I) The direct care registered nurse-to-patient
25ratio for recently born infants shall be 1:4 or fewer
26at all times.

27(xii) The direct care registered nurse-to-patient
28ratio for pediatrics shall be 1:3 or fewer at all times.

29(xiii) The direct care registered nurse-to-patient
30ratio in telemetry shall be 1:3 or fewer at all times.

1(xiv) (A) The direct care registered nurse-to-
2patient ratio in medical/surgical shall be 1:4 or
3fewer at all times.

4(B) The direct care registered nurse-to-patient
5ratios for presurgical and admissions units or
6ambulatory surgical units shall be 1:4 or fewer at
7all times.

8(xv) The direct care registered nurse-to-patient
9ratio in other specialty units shall be 1:4 or fewer at
10all times.

11(xvi) The direct care registered nurse-to-patient
12ratio in psychiatric units shall be 1:4 or fewer at all
13times.

14(xvii) The direct care registered nurse-to-patient
15ratio in a rehabilitation unit or a skilled nursing
16facility shall be 1:5 or fewer at all times.

17(c) Additional conditions.--

18(1) Identifying a unit or clinical patient care area by
19a name or term other than those defined in section 833-A does
20not affect the requirement to staff at the direct care
21registered nurse-to-patient ratios identified for the level
22of intensity or type of care described in section 833-A and
23this section.

24(2) (i) Patients shall only be cared for on units or
25clinical patient care areas where the level of intensity,
26type of care and direct care registered nurse-to-patients
27ratios meet the individual requirements and needs of each
28patient.

29(ii) The use of patient acuity-adjustable units or
30clinical patient care areas is prohibited.

1(3) Video cameras or monitors or any form of electronic
2visualization of a patient shall not be deemed a substitute
3for the direct observation required for patient assessment by
4the direct care registered nurse and for patient protection
5required by an attendant or sitter.

6Section 841-A. Hospital unit staffing plans.

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

8(1) In addition to the direct care registered nurse
9ratio requirements of subsection (b), a hospital shall assign
10additional nursing staff, such as licensed practical nurses
11and certified nursing assistants, through the implementation
12of a valid acuity-based patient classification system for
13determining nursing care needs of individual patients that
14reflects the assessment made by the assigned direct care
15registered nurse of patient nursing care requirements and
16provides for shift-by-shift staffing based on those
17requirements.

18(2) The ratios specified in subsection (b) shall
19constitute the minimum number of registered nurses who shall
20be assigned to direct patient care. Additional registered
21nursing staff in excess of the prescribed ratios shall be
22assigned to direct patient care in accordance with the
23hospital's implementation of a valid system for determining
24nursing care requirements.

25(3) Based on the direct care registered nurse assessment
26as reflected in the implementation of a valid system and
27independent direct care registered nurse determination of
28patient care needs, additional licensed and nonlicensed staff
29shall be assigned.

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

1(1) A written staffing plan shall be developed by the
2chief nursing officer or a designee, based on individual
3patient care needs determined by the system. The staffing
4plan shall be developed and implemented for each patient care
5unit and shall specify individual patient care requirements
6and the staffing levels for direct care registered nurses and
7other licensed and unlicensed personnel.

8(2) In no case may the staffing level for direct care
9registered nurses on any shifts fall below the requirements
10of this subsection.

11(3) The plan shall include the following:

12(i) Staffing requirements as determined by the
13system for each unit, documented and posted on the unit
14for public view on a day-to-day, shift-by-shift basis.

15(ii) The actual staff and staff mix provided,
16documented and posted on the unit for public view on a
17day-to-day, shift-by-shift basis.

18(iii) The variance between required and actual
19staffing patterns, documented and posted on the unit for
20public view on a day-to-day, shift-by-shift basis.

21(c) Recordkeeping.--In addition to the documentation
22required in subsection (b), the hospital shall keep a record of
23the actual direct care registered nurse, licensed practical
24nurse and certified nursing assistant assignments to individual
25patients by licensure category, documented on a day-to-day,
26shift-by-shift basis. The hospital shall retain:

27(1) The staffing plan required in subsection (b) for a
28period of two years.

29(2) The record of the actual direct care registered
30nurse, licensed practical nurse and certified nursing

1assistant assignments by licensure and nonlicensure category.

2(d) Review committee to conduct annual review of system.--
3The reliability of the system for validating staffing
4requirements shall be reviewed at least annually by a committee
5to determine whether the system accurately measures individual
6patient care needs and completely predicts direct care
7registered nurse, licensed practical nurse and certified nursing
8assistant staffing requirements based exclusively on individual
9patient needs.

10(e) Review committee membership.--

11(1) At least half of the members of the review committee
12shall be unit-specific, competent direct care registered
13nurses who provide direct patient care.

14(2) The members of the committee shall be appointed by
15the chief nurse officer, except where direct care registered
16nurses are represented for collective bargaining purposes,
17all direct care registered nurses on the committee shall be
18appointed by the authorized collective bargaining agent.

19(3) In case of a dispute, the direct care registered
20nurse assessment shall prevail.

21(f) Time period for adjustments.--If the review committee
22determines that adjustments are necessary in order to assure
23accuracy in measuring patient care needs, the adjustments shall
24be implemented within 30 days of that determination.

25(g) Process for staff input.--A hospital shall develop and
26document a process by which all interested staff may provide
27input about the system's required revisions and the overall
28staffing plan.

29(h) Limitation on administrator of nursing services.--The
30administrator of nursing services may not be designated to serve

1as a charge nurse or to have direct patient care responsibility.

2(i) Minimum requirement for each shift.--Each patient care
3unit shall have at least one direct care registered nurse
4assigned, present and responsible for the patient care in the
5unit on each shift.

6(j) Temporary nursing agencies.--

7(1) Nursing personnel from temporary nursing agencies
8may not be responsible for patient care on any clinical unit
9without having demonstrated and validated clinical competency
10on the assigned unit.

11(2) A hospital that utilizes temporary nursing agencies
12shall have and adhere to a written procedure to orient and
13evaluate personnel from these sources. In order to ensure
14clinical competence of temporary agency personnel, the
15procedures shall require that personnel from temporary
16nursing agencies be evaluated as often, or more often, than
17staff employed directly by the hospital.

18(k) Planning for routine fluctuations.--

19(1) A hospital shall plan for routine fluctuations, such
20as admissions, discharges and transfers in patient census.

21(2) If a health care emergency causes a change in the
22number of patients on a unit, the hospital shall demonstrate
23that immediate and diligent efforts were made to maintain
24required staffing levels.

25(3) For purposes of this subsection, a "health care"
26emergency is defined as an emergency declared by the Federal
27Government or the head of a State, local, county or municipal
28government.

29Section 842-A. Minimum requirements for hospital systems.

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

1(1) Adopt an acuity-based patient classification system,
2including a written nursing care staffing plan for each
3patient care unit.

4(2) Implement, evaluate and modify the plan as necessary
5and appropriate under the provisions of this section.

6(3) Provide direct care nurse staffing based on
7individual patient need determined in accordance with the
8requirements of this section.

9(4) Use the system to determine additional direct care
10registered nursing staffing above the minimum staffing ratios
11required by subsection (b) and any staffing by licensed
12practical nurses or unlicensed nursing personnel.

13(b) Required elements.--The system used by a hospital for
14determining patient nursing care needs shall include, but not be
15limited to, the following elements:

16(1) A method to predict nursing care requirements of
17individual patient assessments and as determined by direct
18care registered nurse assessments of individual patients.

19(2) A method that provides for sufficient direct care
20registered nursing staffing to ensure that all of the
21elements in this subsection are performed in the planning and
22delivery of care for each patient:

23(i) assessment;

24(ii) nursing diagnosis;

25(iii) planning; and

26(iv) intervention.

27(3) An established method by which the amount of nursing
28care needed for each category of patient is validated.

29(4) A method for validation of the reliability of the
30system.

1(c) Transparency of system.--

2(1) A system shall be fully transparent in all respects,
3including:

4(i) Disclosure of detailed documentation of the
5methodology used by the system to predict nursing
6staffing.

7(ii) Identification of each factor, assumption and
8value used in applying the methodology.

9(iii) An explanation of the scientific and empirical
10basis for each assumption and value and certification by
11a knowledgeable and authorized representative of the
12hospital that the disclosures regarding methods used for
13testing and validating the accuracy and reliability of
14the system are true and complete.

15(2) A hospital shall include in the documentation
16required by this section an evaluation and a report on at
17least an annual basis, which evaluation and report shall be
18conducted and prepared by a committee consisting exclusively
19of direct care registered nurses who have provided direct
20patient care in the units covered by the system. Where direct
21care registered nurses are represented for collective
22bargaining purposes, all direct care registered nurses on the
23committee shall be appointed by the authorized collective
24bargaining agent.

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

26(1) The documentation required by this section shall be
27submitted in its entirety to the Department of Health as a
28mandatory condition of hospital licensure, with a
29certification by the chief nurse officer for the hospital
30that it completely and accurately reflects implementation of

1a valid system used to determine nursing service staffing by
2the hospital for every shift on every clinical unit in which
3patients reside and receive care.

4(2) The certification shall be executed by the chief
5nurse officer under penalty of perjury and shall contain an
6express acknowledgment that any false statement in the
7certification shall constitute fraud and be subject to
8criminal and civil prosecution and penalties under the
9antifraud provisions applicable to false claims for
10government funds or benefits.

11(3) The documentation shall be available for public
12inspection in its entirety in accordance with procedures
13established by appropriate administrative regulation
14consistent with the purposes of this chapter.

15Section 843-A. Prohibited activities.

16The following activities are prohibited:

17(1) A hospital may not directly assign any unlicensed
18personnel to perform registered nurse functions in lieu of
19care delivered by a licensed registered nurse and may not
20assign unlicensed personnel to perform registered nurse
21functions under the clinical supervision of a direct care
22registered nurse.

23(2) Unlicensed personnel may not perform tasks that
24require the clinical assessment, judgment and skill of a
25licensed registered nurse, including, without limitation:

26(i) Nursing activities that require nursing
27assessment and judgment during implementation.

28(ii) Physical, psychological and social assessments
29that require nursing judgment, intervention, referral or
30follow-up.

1(iii) Formulation of a plan of nursing care and
2evaluation of the patient's response to the care
3provided.

4(iv) Administration of medication, venipuncture or
5intravenous therapy, parenteral or tube feedings,
6invasive procedures, including inserting nasogastric
7tubes, inserting catheters or tracheal suctioning.

8(v) Educating patients and their families concerning
9the patient's health care problems, including
10postdischarge care.

11(c) Mandatory overtime.--A hospital may not impose mandatory
12overtime requirements to meet the staffing ratios imposed in
13section 840-A.

14Section 844-A. Fines and civil penalties.

15The following fines and penalties shall apply to violations
16of this chapter:

17(1) A hospital found to have violated or aided and
18abetted section 841-A, 842-A or 843-A shall be subject, in
19addition to any other penalties that may be prescribed by
20law, to a civil penalty of not more than $25,000 for each
21violation and an additional $10,000 per nursing unit shift
22until the violation is corrected.

23(2) A hospital employer found to have violated or
24interfered with any of the rights or protections provided and
25guaranteed under sections 836-A, 837-A, 838-A, 839-A and

26840-A shall be subject to a civil penalty of not more than
27$25,000 for each violation or occurrence of prohibited
28conduct.

29(3) A hospital management, nursing service or medical
30personnel found to have violated or interfered with any of

1the rights or protections provided and guaranteed under
2sections 836-A, 837-A, 838-A, 839-A and 840-A shall be
3subject to a civil penalty of not more than $20,000 for each
4violation or occurrence of prohibited conduct.

5Section 845-A. Private right of action.

6(a) General rule.--A health care facility that violates the
7rights of an employee specified in sections 835-A, 836-A, 837-A,
8838-A and 839-A may be held liable to the employee in an action
9brought in a court of competent jurisdiction for such legal or
10equitable relief as may be appropriate to effectuate the
11purposes of this chapter, including, but not limited to,
12reinstatement, promotion, lost wages and benefits and
13compensatory and consequential damages resulting from the
14violations together with an equal amount in liquidated damages.
15The court in the action shall, in addition to any judgment
16awarded to the plaintiffs, award reasonable attorney fees and
17costs of action to be paid by the defendants. The employee's
18right to institute a private action is not limited by any other
19rights granted under this chapter.

20(b) Relief for nurses.--In addition to the amount recovered
21under subsection (a), a nurse whose employment is suspended or
22terminated in violation of this section is entitled to:

23(1) Reinstatement in the nurse's former position or
24severance pay in an amount equal to three months of the
25nurse's most recent salary.

26(2) Compensation for wages lost during the period of
27suspension or termination.

28(3) An award of reasonable attorney fees and costs as
29the prevailing party.

30Section 846-A. Enforcement procedure.

1(a) Period of limitations.--

2(1) Except as otherwise provided in paragraph (2), in
3the case of an action brought for a willful violation of the
4applicable provisions of this chapter, the action must be
5brought within three years of the date of the last event
6constituting the alleged violation for which the action is
7brought.

8(2) An action must be brought under section 845-A no
9later than two years after the date of the last event
10constituting the alleged violation for which the action is
11brought.

12(b) Posting requirements.--A hospital and other medical
13facility shall post the provisions of this chapter in a
14prominent place for review by the public and the employees. The
15posting shall have a title across the top in no less than 35
16point, bold typeface stating the following:

17"RIGHTS OF REGISTERED NURSES AS PATIENT ADVOCATES, EMPLOYEES
18AND PATIENTS."

19Section 2. This act shall take effect in 60 days.