HB2604ham001 101ST GENERAL ASSEMBLY

Rep. Fred Crespo

Filed: 3/19/2019

10100HB2604ham001 LRB101 08483 CPF 57938 a

AMENDMENT TO HOUSE BILL 2604

AMENDMENT NO. ______. Amend House Bill 2604 by replacing everything after the enacting clause with the following:

"Section 1. Short title. This Act may be cited as the Safe Patient Limits Act.

Section 5. Definitions. In this Act:

"Couplet" means one mother and one baby.

"Critical trauma patient" means a patient who has an injury to an anatomic area that (i) requires life-saving interventions, or (ii) in conjunction with unstable vital signs, poses an immediate threat to life or limb.

"Department" means the Department of Public Health.

"Facility" means a hospital licensed under the Hospital Licensing Act or organized under the University of Illinois Hospital Act, a private or State-owned and State-operated general acute care hospital, an acute psychiatric hospital, an acute care specialty hospital, or an acute care unit within a health care facility.

"Health care workforce" means personnel employed by or contracted to work at a facility that have an effect upon the delivery of quality care to patients, including, but not limited to, registered nurses, licensed practical nurses, unlicensed assistive personnel, service, maintenance, clerical, professional, and technical workers, and other health care workers.

"Immediate postpartum patients" means those patients who have given birth within the previous 2 hours.

"Nursing care" means care that falls within the scope of practice as defined in the Nurse Practice Act or is otherwise encompassed within recognized standards of nursing practice, including assessment, nursing diagnosis, planning, intervention, evaluation, and patient advocacy.

"Registered nurse" means a competent registered nurse who has accepted a direct, hands-on patient care assignment to implement the nursing care plan for that patient and the nursing process while, at all times, exercising independent professional judgment in the exclusive interest of the patient.

"Specialty care unit" means a unit which is organized, operated, and maintained to provide care for a specific medical condition or a specific patient population.

For the purposes of this Act, a patient is considered assigned to a registered nurse if the registered nurse accepts responsibility for the patient's nursing care.

Section 10. Maximum patient assignments for registered nurses.

(a) The maximum number of patients assigned to a registered nurse in a facility shall not exceed the limits provided in this Section. However, nothing shall preclude a facility from assigning fewer patients to a registered nurse than the limits provided in this Section.

(b) In all units with critical care or intensive care patients, including, but not limited to, coronary care, acute respiratory, burn, or neonatal intensive care patients, the maximum patient assignment of critical care patients to a registered nurse is 2.

(c) In all units with step-down or intermediate care patients, the maximum patient assignment of step-down or intermediate care patients to a registered nurse is 3.

(d) In all units with postanesthesia care patients, the maximum patient assignment of postanesthesia care patients under the age of 18 to a registered nurse is one. The maximum patient assignment of postanesthesia care patients 18 years of age or older to a registered nurse is 2.

(e) In all units with operating room patients, the maximum patient assignment of operating room patients to a registered nurse is one, provided that a minimum of one additional person serves as a scrub assistant for each patient.

(f) In the emergency department:

(1) In a unit providing basic emergency medical services or comprehensive emergency medical services, the maximum patient assignment at any time to a registered nurse is 3.

(2) The maximum assignment of critical care emergency patients to a registered nurse is 2. A patient in the emergency department shall be considered a critical care patient when the patient meets the criteria for admission to a critical care service area within the hospital.

(3) The maximum assignment of critical trauma patients in an emergency unit to a registered nurse is one.

(4) At least one direct care registered professional nurse shall be assigned to triage patients. The direct care registered professional nurse assigned to triage patients shall be immediately available at all times to triage patients when they arrive in the emergency department. The direct care registered professional nurse assigned to triage patients shall perform triage functions only.

(g) In all units with maternal child care patients:

(1) The maximum patient assignment to a registered nurse of antepartum patients requiring continuous fetal monitoring is 2.

(2) The maximum patient assignment of other antepartum patients to a registered nurse is 3.

(3) The maximum patient assignment of active labor patients to a registered nurse is one.

(4) The maximum patient assignment during birth is one registered nurse responsible for the mother and, for each baby born, one registered nurse whose sole responsibility is that baby.

(5) The maximum patient assignment of immediate postpartum patients is one couplet, and in the case of multiple births, one nurse for each additional baby.

(6) The maximum patient assignment of postpartum patients to a registered nurse is 6 patients or 3 couplets.

(h) In all units with pediatric patients, the maximum patient assignment of pediatric patients to a registered nurse is 4.

(i) In all units with psychiatric patients, the maximum patient assignment of psychiatric patients to a registered nurse is 4.

(j) In all units with medical and surgical patients, the maximum patient assignment of medical or surgical patients to a registered nurse is 4.

(k) In all units with telemetry patients, the maximum patient assignment of telemetry patients to a registered nurse is 3.

(l) In all units with observational patients, the maximum patient assignment of observational patients to a registered nurse is 4.

(m) In all units with acute rehabilitation patients, the maximum patient assignment of acute rehabilitation patients to a registered nurse is 4.

(n) In all specialty care units, the maximum patient assignment to a registered nurse is 4.

(o) In all units with conscious sedation patients, the maximum patient assignment of conscious sedation patients to a registered nurse is one.

(p) In any unit not otherwise listed in this Section, the maximum patient assignment to a registered nurse is 4.

Section 15. Use of rapid response teams as first responders prohibited. A rapid response team nurse shall not be given direct care patient assignments while assigned as a nurse responsible for responding to a rapid response team request.

Section 20. Implementation by a facility.

(a) A facility shall implement the patient limits established by Section 10 without diminishing the staffing levels of the facility's health care workforce.

(b) There shall be no averaging of the number of patients and the total number of registered nurses in each clinical unit or patient care area in order to meet the limits established under this Act.

(c) Only registered nurses providing direct patient care must comply with the patient limits under Section 10. Nurse administrators, nurse supervisors, nurse managers, charge nurses, case managers, ancillary staff, unlicensed personnel, or any other hospital administrator or supervisor shall not be required to comply with the patient limits under Section 10.

(d) Identifying a clinical unit or patient care area by a name or term other than those listed in this Act does not affect a facility's requirement to staff the unit consistent with the patient limits identified for the level of intensity or type of care described in this Act.

(e) A registered nurse providing direct care to a patient has the authority to determine if a change in the patient's status places the patient in a different category requiring a different patient limit under Section 10.

(f) A registered nurse may determine that additional ancillary staff, such as licensed practical nurses, certified nursing assistants, or other ancillary staff, excluding medical assistants, are needed in order to provide safe care.

(g) A facility shall not employ video monitors or any form of electronic visualization of a patient as a substitute for the direct observation required for patient assessment by the registered nurse or for patient protection. Video monitors or any form of electronic visualization of a patient shall not constitute compliance with the patient limits under Section 10.

Section 25. Changes in patient census.

(a) A facility shall plan for routine fluctuations in its patient census, including, but not limited to, admissions, discharges, and transfers.

(b) If a health care emergency causes a change in the number of patients in a clinical care unit or patient care area, a facility must be able to demonstrate that immediate and diligent efforts were made to maintain required staffing levels under this Act. For purposes of this subsection, "health care emergency" means an emergency declared by the federal government or the head of a State or local governmental entity.

Section 30. Record of staff assignments. A facility shall keep a record of the actual direct care registered professional nurse, licensed practical nurse, certified nursing assistant, and other ancillary staff assignments to individual patients documented on a day-to-day, shift-by-shift basis and shall keep copies of its staff assignments on file for a period of 7 years.

Section 35. Implementation by the Department. The Department shall adopt rules governing the implementation and operation of this Act.

Section 40. Patient acuity systems. Nothing in this Act precludes the use of patient acuity systems consistent with Section 10.10 of the Hospital Licensing Act. However, the maximum patient assignments in Section 10 shall not be exceeded regardless of the use and application of any patient acuity system.

Any method, software, or tool used to create or evaluate a staffing plan adopted by a facility shall be established in coordination with direct care registered professional nurses and shall be transparent in all respects, including disclosure of detailed documentation of the methodology used to determine nurse staffing and identifying each factor, assumption, and value used in applying the methodology. The Department shall establish procedures to ensure that the documentation submitted under this Section is available for public inspection in its entirety.

Section 45. Training. All facilities shall adopt written policies and procedures for the training and orientation of nursing staff. No registered nurse shall be assigned to a nursing unit or clinical area unless that nurse has first received training and orientation in that clinical area that is sufficient to provide competent care to patients in that area and has demonstrated competence in providing care in that area. The written policies and procedures for that training and orientation of nursing staff shall require that all temporary personnel receive the same amount and type of training and orientation that is required for permanent staff.

Section 50. Enforcement. A facility's failure to adhere to the limits set by Section 10 shall be reported by the Department to the Attorney General for enforcement, for which the Attorney General may bring action in a court of competent jurisdiction seeking injunctive relief and civil penalties. A separate and distinct violation, for which the facility shall be subject to a civil penalty of up to $25,000, shall be deemed to have been committed on each day during which any violation continues after receipt of written notice of the violation from the Department by the facility. The requirements of this Act, and its enforcement, shall be suspended during a public health emergency declared by the State or federal government.

Section 55. Whistleblower protection.

(a) A registered professional nurse may object to or refuse to participate in any activity, practice, assignment, or task if:

(1) in good faith, the nurse reasonably believes it to be a violation of the direct care registered professional nurse-to-patient ratios established under this Act; or

(2) the nurse is not prepared by education, training, or experience to fulfill the assignment without compromising the safety of any patient or jeopardizing the license of the nurse.

(b) A facility shall not retaliate, discriminate, or otherwise take adverse action in any manner with respect to any aspect of a nurse's employment, including discharge, promotion, compensation, or terms, conditions, or privileges of employment, based on the nurse's refusal to complete an assignment under subsection (a).

(c) A facility shall not file a complaint against a registered professional nurse with the Board of Nursing based on the nurse's refusal to complete an assignment under subsection (a).

(d) A facility shall not retaliate, discriminate, or otherwise take adverse action in any manner against any person or with respect to any aspect of a nurse's employment, including discharge, promotion, compensation, or terms, conditions, or privileges of employment, based on that nurse's or that person's opposition to any hospital policy, practice, or action that the nurse in good faith believes violates this Act.

(e) A facility shall not retaliate, discriminate, or otherwise take adverse action against any patient or employee of the facility or any other individual on the basis that the patient, employee, or individual, in good faith, individually or in conjunction with another person or persons, has presented a grievance or complaint, or has initiated or cooperated in any investigation or proceeding of any governmental entity, regulatory agency, or private accreditation body, made a civil claim or demand, or filed an action relating to the care, services, or conditions of the facility or of any affiliated or related facilities.

(f) A facility shall not do either of the following:

(1) Interfere with, restrain, or deny the exercise of, or attempt to deny the exercise of, a right conferred under this Act.

(2) Coerce or intimidate any individual regarding the exercise of, or an attempt to exercise, a right conferred by this Act.

Section 60. Severability. The provisions of this Act are severable, and if any clause, sentence, paragraph, subsection, or Section of this law or any application thereof shall be adjudged by any court of competent jurisdiction to be invalid, such judgment shall not affect, impair, or invalidate the remainder thereof but shall be confined in its operation to the clause, sentence, paragraph, subsection, Section, or application adjudged invalid and such clause, sentence, paragraph, subsection, Section, or application shall be reformed and construed so that it would be valid to the maximum extent permitted.

Section 85. The Hospital Licensing Act is amended by changing Section 10.10 as follows:

(210 ILCS 85/10.10)

Sec. 10.10. Nurse Staffing by Patient Acuity.

(a) Findings. The Legislature finds and declares all of the following:

(1) The State of Illinois has a substantial interest in promoting quality care and improving the delivery of health care services.

(2) Evidence-based studies have shown that the basic principles of staffing in the acute care setting should be based on the complexity of patients' care needs aligned with available nursing skills to promote quality patient care consistent with professional nursing standards.

(3) Compliance with this Section promotes an organizational climate that values registered nurses' input in meeting the health care needs of hospital patients.

(b) Definitions. As used in this Section:

"Acuity model" means an assessment tool selected and implemented by a hospital, as recommended by a nursing care committee, that assesses the complexity of patient care needs requiring professional nursing care and skills and aligns patient care needs and nursing skills consistent with professional nursing standards.

"Department" means the Department of Public Health.

"Direct patient care" means care provided by a registered professional nurse with direct responsibility to oversee or carry out medical regimens or nursing care for one or more patients.

"Nursing care committee" means an existing or newly created hospital-wide committee or committees of nurses whose functions, in part or in whole, contribute to the development, recommendation, and review of the hospital's nurse staffing plan established pursuant to subsection (d).

"Registered professional nurse" means a person licensed as a Registered Nurse under the Nurse Practice Act.

"Written staffing plan for nursing care services" means a written plan for guiding the assignment of patient care nursing staff based on multiple nurse and patient considerations that yield minimum staffing levels for inpatient care units and the adopted acuity model aligning patient care needs with nursing skills required for quality patient care consistent with professional nursing standards.

(c) Written staffing plan.

(1) Every hospital shall implement a written hospital-wide staffing plan, recommended by a nursing care committee or committees, that provides for minimum direct care professional registered nurse-to-patient staffing needs for each inpatient care unit. The written hospital-wide staffing plan shall include, but need not be limited to, the following considerations:

(A) The complexity of complete care, assessment on patient admission, volume of patient admissions, discharges and transfers, evaluation of the progress of a patient's problems, ongoing physical assessments, planning for a patient's discharge, assessment after a change in patient condition, and assessment of the need for patient referrals.

(B) The complexity of clinical professional nursing judgment needed to design and implement a patient's nursing care plan, the need for specialized equipment and technology, the skill mix of other personnel providing or supporting direct patient care, and involvement in quality improvement activities, professional preparation, and experience.

(C) Patient acuity and the number of patients for whom care is being provided.

(D) The ongoing assessments of a unit's patient acuity levels and nursing staff needed shall be routinely made by the unit nurse manager or his or her designee.

(E) The identification of additional registered nurses available for direct patient care when patients' unexpected needs exceed the planned workload for direct care staff.

(2) In order to provide staffing flexibility to meet patient needs, every hospital shall identify an acuity model for adjusting the staffing plan for each inpatient care unit.

(3) The written staffing plan shall be posted in a conspicuous and accessible location for both patients and direct care staff, as required under the Hospital Report Card Act. A copy of the written staffing plan shall be provided to any member of the general public upon request.

(d) Nursing care committee.

(1) Every hospital shall have a nursing care committee. A hospital shall appoint members of a committee whereby at least 50% of the members are registered professional nurses providing direct patient care.

(2) A nursing care committee's recommendations must be given significant regard and weight in the hospital's adoption and implementation of a written staffing plan.

(3) A nursing care committee or committees shall recommend a written staffing plan for the hospital based on the principles from the staffing components set forth in subsection (c). In particular, a committee or committees shall provide input and feedback on the following:

(A) Selection, implementation, and evaluation of minimum staffing levels for inpatient care units.

(B) Selection, implementation, and evaluation of an acuity model to provide staffing flexibility that aligns changing patient acuity with nursing skills required.

(C) Selection, implementation, and evaluation of a written staffing plan incorporating the items described in subdivisions (c)(1) and (c)(2) of this Section.

(D) Review the following: nurse-to-patient staffing guidelines for all inpatient areas; and current acuity tools and measures in use.

(4) A nursing care committee must address the items described in subparagraphs (A) through (D) of paragraph (3) semi-annually.

(e) Nothing in this Section 10.10 shall be construed to limit, alter, or modify any of the terms, conditions, or provisions of a collective bargaining agreement entered into by the hospital.

(f) A hospital shall not directly assign any unlicensed personnel to perform registered professional nurse functions in lieu of care delivered by a registered professional nurse and shall not assign unlicensed personnel to perform registered professional nurse functions under the supervision of a direct care registered professional nurse.

(g) Unlicensed personnel shall not be required to perform tasks that require the clinical assessment, professional judgment, and skill of a licensed registered professional nurse, including, but not limited to, the following: activities that require a nursing assessment or nursing judgment during implementation; physical, psychological, and social assessments that require nursing judgment, intervention, referral, or follow-up; formulation of a plan of nursing care and evaluation of a patient's response to the care provided; and administration of medications.

(Source: P.A. 96-328, eff. 8-11-09; 97-423, eff. 1-1-12; 97-813, eff. 7-13-12.)

Section 90. The Nurse Practice Act is amended by adding Sections 50-15.1, 50-15.5, 50-15.10, and 50-15.15 as follows:

(225 ILCS 65/50-15.1 new)

Sec. 50-15.1. Functions generally.

(a) A direct care registered professional nurse, holding a valid license to practice as a registered professional nurse, employing scientific knowledge and experience in the physical, social, and biological sciences, and exercising independent professional judgment in applying the nursing process in the exclusive interests of a patient, shall directly perform the following essential functions:

(1) Continuous and ongoing comprehensive nursing assessments of a patient's condition based upon the independent professional judgment of the direct care registered professional nurse.

(2) Planning, implementation, and evaluation of the nursing care provided to each patient. The implementation of nursing care may be assigned by the direct care registered professional nurse responsible for the patient to other licensed nursing staff or to unlicensed staff, subject to any limitations of the licensure, certification, level of validated competency, or applicable law concerning such staff. In any case, however:

(A) The direct care registered professional nurse assigned to a patient must determine in her or his professional judgment that nursing personnel to be assigned patient care tasks possess the necessary preparation and capability to competently perform the assigned tasks.

(B) The direct care registered professional nurse may assign the implementation of nursing care only when the registered professional nurse is physically present and available.

(3) Assessment, planning, implementation, and evaluation of patient education, including ongoing discharge education of each patient.

(b) The planning and delivery of patient care shall: (i) reflect all elements of the nursing process, including comprehensive nursing assessment, nursing diagnosis, planning, intervention, evaluation, and, as circumstances require, patient advocacy; and (ii) be initiated by a direct care registered professional nurse at the time of a patient's admission to the hospital.

(c) A nursing plan for a patient's care shall be discussed with and developed as a result of coordination with the patient, the patient's family, or other representatives of the patient, when appropriate, and staff of other disciplines involved in the care of the patient.

(d) A direct care registered professional nurse shall evaluate the effectiveness of the care plan through: (i) comprehensive nursing assessments based on direct observation of the patient's physical condition and behavior, signs and symptoms of illness, and reactions to treatment; and (ii) communication with the patient and other caregivers as applicable. The direct care registered professional nurse shall modify the plan as needed.

(e) Information related to the patient's initial comprehensive nursing assessment and reassessments, nursing diagnosis, plan, intervention, evaluation, and patient advocacy shall be permanently recorded, as narrative registered professional nurse progress notes, in the patient's medical record. The practice of "charting by exception" is expressly prohibited.

(225 ILCS 65/50-15.5 new)

Sec. 50-15.5. Patient assessment.

(a) Patient assessment requires: (i) direct observation of the patient's signs and symptoms of illness, reaction to treatment, behavior and physical condition; and (ii) interpretation of information obtained from the patient and others, including other caregivers, as applicable.

(b) Only a direct care registered professional nurse who is physically present with the patient is authorized to perform patient assessments. A licensed practical nurse may assist a direct care registered professional nurse in data collection.

(225 ILCS 65/50-15.10 new)

Sec. 50-15.10. Determining nursing care needs of patients.

(a) The nursing care needs of each individual patient shall be determined by a direct care registered professional nurse through the process of ongoing comprehensive nursing assessments, nursing diagnosis, and formulation and adjustment of nursing care plans.

(b) The prediction of individual patient nursing care needs for prospective assignment of direct care registered professional nurses shall be based on individual comprehensive nursing assessments by the direct care registered professional nurse assigned to each patient.

(225 ILCS 65/50-15.15 new)

Sec. 50-15.15. Independent professional judgment.

(a) Competent performance of the essential functions of a direct care registered professional nurse requires the exercise of independent professional judgment in the exclusive interests of the patient. The exercise of such independent professional judgment, unencumbered by the commercial or revenue-generation priorities of a hospital, long term acute care hospital, or ambulatory surgical treatment center or other employing entity of a direct care registered professional nurse, is necessary to ensure safe, therapeutic, effective, and competent treatment of hospital patients and is essential to protect the health and safety of the people of Illinois.

(b) The exercise of independent professional judgment by a direct care registered professional nurse in the performance of the essential functions, as described in paragraphs (1), (2), and (3) of subsection (a) of Section 15-1, shall be provided in the exclusive interests of the patient and shall not, for any purpose, be considered, relied upon, or represented as a job function, authority, responsibility, or activity undertaken in any respect for the purpose of serving the business, commercial, operational, or other institutional interests of the hospital.

(c) No hospital, long term acute care hospital, ambulatory surgical treatment center, or other health care institution shall utilize technology that:

(1) limits a direct care registered professional nurse in performing functions that are part of the nursing process, including full exercise of independent professional judgment in assessment, planning, implementation and evaluation of care; or

(2) limits a direct care registered professional nurse in acting as a patient advocate in the exclusive interests of the patient.

Technology shall not be skill-degrading, interfere with a direct care registered professional nurse's provision of individualized patient care, or override a direct care registered professional nurse's independent professional judgment.".