Illinois General Assembly - Full Text of HB3871
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Full Text of HB3871  102nd General Assembly




State of Illinois
2021 and 2022


Introduced 2/22/2021, by Rep. Fred Crespo


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    Creates the Safe Patient Limits Act. Provides the maximum number of patients that may be assigned to a registered nurse in specified situations. Provides that nothing shall preclude a facility from assigning fewer patients to a registered nurse than the limits provided in Act. Provides that nothing in the Act precludes the use of patient acuity systems consistent with the Nurse Staffing by Patient Acuity Act; however, the maximum patient assignments in the Act may not be exceeded, regardless of the use and application of any patient acuity system. Provides that the Department of Public Health shall adopt rules governing the implementation and operation of the Act. Provides that all facilities shall adopt written policies and procedures for training and orientation of nursing staff and that no registered nurse shall be assigned to a nursing unit or clinical area unless that nurse has, among other things, demonstrated competence in providing care in that area. Provides specified requirements for the Act's implementation by a facility. Establishes recordkeeping requirements. Provides that the written policies and procedures for the 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. Provides specified nurse rights and protections. Provides that the Act's provisions are severable. Contains other provisions. Amends the Hospital Licensing Act. Provides that a hospital shall not mandate that a registered professional nurse delegate nursing interventions. Amends the Nurse Practice Act. Provides that the exercise of professional judgment by a direct care registered professional nurse in the performance of his or her scope of practice shall be provided in the exclusive interests of the patient.

LRB102 14828 CPF 20181 b






HB3871LRB102 14828 CPF 20181 b

1    AN ACT concerning health.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 1. Short title. This Act may be cited as the Safe
5Patient Limits Act.
6    Section 5. Definitions. In this Act:
7    "Couplet" means one mother and one baby.
8    "Critical trauma patient" means a patient who has an
9injury to an anatomic area that (i) requires life-saving
10interventions, or (ii) in conjunction with unstable vital
11signs, poses an immediate threat to life or limb.
12    "Department" means the Department of Public Health.
13    "Direct care registered professional nurse" means a
14registered professional nurse whose primary role is to provide
15direct hands-on patient care.
16    "Facility" means a hospital licensed under the Hospital
17Licensing Act or organized under the University of Illinois
18Hospital Act, a private or State-owned and State-operated
19general acute care hospital, an LTAC hospital as defined in
20Section 10 of the Long Term Acute Care Hospital Quality
21Improvement Transfer Program Act, an ambulatory surgical
22treatment center as defined in Section 3 of the Ambulatory
23Surgical Treatment Center Act, an acute psychiatric hospital,



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1an acute care specialty hospital, or an acute care unit within
2a health care facility. "Facility" does not include: (1) the
3Alton Mental Health Center, at Alton; (2) the Chicago-Read
4Mental Health Center, at Chicago; (3) the Clyde L. Choate
5Mental Health and Developmental Center, at Anna; (4) the Elgin
6Mental Health Center, at Elgin; (5) the John J. Madden Mental
7Health Center, at Chicago; (6) the Andrew McFarland Mental
8Health Center, at Springfield; and (7) the Chester Mental
9Health Center, at Chester.
10    "Health care workforce" means personnel employed by or
11contracted to work at a facility that have an effect upon the
12delivery of quality care to patients, including, but not
13limited to, registered nurses, licensed practical nurses,
14unlicensed assistive personnel, service, maintenance,
15clerical, professional, and technical workers, and other
16health care workers.
17    "Immediate postpartum patients" means those patients who
18have given birth within the previous 2 hours.
19    "Nursing care" means care that falls within the scope of
20practice as described in Section 55-30 or 60-35 of the Nurse
21Practice Act or is otherwise encompassed within recognized
22standards of nursing practice.
23    "Rapid response team" means a team of health care
24providers that provide care to hospitalized patients with
25early signs of deterioration to prevent respiratory or cardiac



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1    "Registered nurse" or "registered professional nurse"
2means a person who is licensed as a registered professional
3nurse under the Nurse Practice Act and practices nursing as
4described in Section 60-35 of the Nurse Practice Act.
5    "Specialty care unit" means a unit which is organized,
6operated, and maintained to provide care for a specific
7medical condition or a specific patient population.
8    For the purposes of this Act, a patient is considered
9assigned to a registered nurse if the registered nurse accepts
10responsibility for the patient's nursing care.
11    Section 10. Maximum patient assignments for registered
13    (a) The maximum number of patients assigned to a
14registered nurse in a facility shall not exceed the limits
15provided in this Section. However, nothing shall preclude a
16facility from assigning fewer patients to a registered nurse
17than the limits provided in this Section. The requirements of
18this Section apply at all times during each shift within each
19clinical unit and each patient care area.
20    The requirements of this Section do not apply to: (1) the
21Alton Mental Health Center, at Alton; (2) the Chicago-Read
22Mental Health Center, at Chicago; (3) the Clyde L. Choate
23Mental Health and Developmental Center, at Anna; (4) the Elgin
24Mental Health Center, at Elgin; (5) the John J. Madden Mental
25Health Center, at Chicago; (6) the Andrew McFarland Mental



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1Health Center, at Springfield; and (7) the Chester Mental
2Health Center, at Chester.
3    (b) In all units with critical care or intensive care
4patients, including, but not limited to, coronary care, acute
5respiratory, burn, or neonatal intensive care patients, the
6maximum patient assignment of critical care patients to a
7registered nurse is 2.
8    (c) In all units with step-down or intermediate care
9patients, the maximum patient assignment of step-down or
10intermediate care patients to a registered nurse is 3.
11    (d) In all units with postanesthesia care patients, the
12maximum patient assignment of postanesthesia care patients
13under the age of 18 to a registered nurse is one. The maximum
14patient assignment of postanesthesia care patients 18 years of
15age or older to a registered nurse is 2.
16    (e) In all units with operating room patients, the maximum
17patient assignment of operating room patients to a registered
18nurse is one, provided that a minimum of one additional person
19serves as a scrub assistant for each patient.
20    (f) In the emergency department:
21        (1) In a unit providing basic emergency medical
22    services or comprehensive emergency medical services, the
23    maximum patient assignment at any time to a registered
24    nurse is 3.
25        (2) The maximum assignment of critical care emergency
26    patients to a registered nurse is 2. A patient in the



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1    emergency department shall be considered a critical care
2    patient when the patient meets the criteria for admission
3    to a critical care service area within the hospital.
4        (3) The maximum assignment of critical trauma patients
5    in an emergency unit to a registered nurse is one.
6        (4) At least one direct care registered professional
7    nurse shall be assigned to triage patients. The direct
8    care registered professional nurse assigned to triage
9    patients shall be immediately available at all times to
10    triage patients when they arrive in the emergency
11    department. The direct care registered professional nurse
12    assigned to triage patients shall perform triage functions
13    only.
14    (g) In all units with maternal child care patients:
15        (1) The maximum patient assignment to a registered
16    nurse of antepartum patients requiring continuous fetal
17    monitoring is 2.
18        (2) The maximum patient assignment of other antepartum
19    patients to a registered nurse is 3.
20        (3) The maximum patient assignment of active labor
21    patients to a registered nurse is one.
22        (4) The maximum patient assignment during birth is one
23    registered nurse responsible for the mother and, for each
24    baby born, one registered nurse whose sole responsibility
25    is that baby.
26        (5) The maximum patient assignment of immediate



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1    postpartum patients is one couplet, and in the case of
2    multiple births, one nurse for each additional baby.
3        (6) The maximum patient assignment of postpartum
4    patients to a registered nurse is 6 patients or 3
5    couplets.
6    (h) In all units with pediatric patients, the maximum
7patient assignment of pediatric patients to a registered nurse
8is 3.
9    (i) In all units with psychiatric patients, the maximum
10patient assignment of psychiatric patients to a registered
11nurse is 4.
12    (j) In all units with medical and surgical patients, the
13maximum patient assignment of medical or surgical patients to
14a registered nurse is 4.
15    (k) In all units with telemetry patients, the maximum
16patient assignment of telemetry patients to a registered nurse
17is 3.
18    (l) In all units with observational patients, the maximum
19patient assignment of observational patients to a registered
20nurse is 3.
21    (m) In all units with acute rehabilitation patients, the
22maximum patient assignment of acute rehabilitation patients to
23a registered nurse is 4.
24    (n) In all specialty care units, the maximum patient
25assignment to a registered nurse is 4.
26    (o) In all units with conscious sedation patients, the



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1maximum patient assignment of conscious sedation patients to a
2registered nurse is one.
3    (p) In any unit not otherwise listed in this Section, the
4maximum patient assignment to a registered nurse is 4.
5    Section 15. Use of rapid response teams as first
6responders prohibited. A rapid response team nurse shall not
7be given direct care patient assignments while assigned as a
8nurse responsible for responding to a rapid response team
10    Section 20. Implementation by a facility.
11    (a) A facility shall implement the patient limits
12established by Section 10 without diminishing the staffing
13levels of the facility's health care workforce, as defined in
14Section 5.
15    (b) There shall be no averaging of the number of patients
16and the total number of registered nurses in each clinical
17unit or patient care area in order to meet the limits
18established under this Act.
19    (c) Only registered nurses providing direct patient care
20shall count toward the patient limits under Section 10. Nurse
21administrators, nurse supervisors, nurse managers, charge
22nurses, case managers, ancillary staff, unlicensed personnel,
23or any other hospital administrator or supervisor shall not
24count toward the patient limits under Section 10.



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1    (d) Identifying a clinical unit or patient care area by a
2name or term other than those listed in this Act does not
3affect a facility's requirement to staff the unit consistent
4with the patient limits identified for the level of intensity
5or type of care described in this Act.
6    (e) A registered nurse providing direct care to a patient
7has the authority to determine if a change in the patient's
8status places the patient in a different category requiring a
9different patient limit under Section 10.
10    (f) A registered nurse may determine that additional
11ancillary staff, such as licensed practical nurses, certified
12nursing assistants, or other ancillary staff, excluding
13medical assistants, are needed in order to provide safe care.
14    (g) A facility shall not employ video monitors or any form
15of electronic visualization of a patient as a substitute for
16the direct observation required for patient assessment by the
17registered nurse or for patient protection. Video monitors or
18any form of electronic visualization of a patient shall not
19constitute compliance with the patient limits under Section
21    Section 25. Changes in patient census.
22    (a) A facility shall plan for routine fluctuations in its
23patient census, including, but not limited to, admissions,
24discharges, and transfers.
25    (b) If a health care emergency causes a change in the



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1number of patients in a clinical care unit or patient care
2area, a facility must be able to demonstrate that immediate
3and diligent efforts were made to maintain required staffing
4levels under this Act. For purposes of this subsection,
5"health care emergency" means an emergency declared by the
6federal government or the head of a State or local
7governmental entity.
8    Section 30. Record of staff assignments. A facility shall
9keep a record of the actual direct care registered
10professional nurse, licensed practical nurse, certified
11nursing assistant, and other ancillary staff assignments to
12individual patients documented on a day-to-day, shift-by-shift
13basis and shall keep copies of its staff assignments on file
14for a period of 7 years.
15    Section 35. Implementation by the Department. The
16Department shall adopt rules governing the implementation and
17operation of this Act.
18    Section 40. Patient acuity systems. Nothing in this Act
19precludes the use of patient acuity systems consistent with
20Section 10.10 of the Hospital Licensing Act. However, the
21maximum patient assignments in Section 10 shall not be
22exceeded regardless of the use and application of any patient
23acuity system.



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1    Any method, software, or tool used to create or evaluate a
2staffing plan adopted by a facility shall be established in
3coordination with direct care registered professional nurses
4and shall be transparent in all respects, including disclosure
5of detailed documentation of the methodology used to determine
6nurse staffing and identifying each factor, assumption, and
7value used in applying the methodology. The Department shall
8establish procedures to ensure that the documentation
9submitted under this Section is available for public
10inspection in its entirety.
11    Section 45. Training. All facilities shall adopt written
12policies and procedures for the training and orientation of
13nursing staff. No registered nurse shall be assigned to a
14nursing unit or clinical area unless that nurse has first
15received training and orientation in that clinical area that
16is sufficient to provide competent care to patients in that
17area and has demonstrated competence in providing care in that
19    Section 50. Enforcement. A facility's failure to adhere to
20the limits set by Section 10 shall be reported by the
21Department to the Attorney General for enforcement, for which
22the Attorney General may bring action in a court of competent
23jurisdiction seeking injunctive relief and civil penalties. A
24separate and distinct violation, for which the facility shall



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1be subject to a civil penalty of up to $25,000, shall be deemed
2to have been committed on each day during which any violation
3continues after receipt of written notice of the violation
4from the Department by the facility. The requirements of this
5Act, and its enforcement, shall be suspended during a public
6health emergency declared by the State or federal government.
7    Section 55. Nurse rights and protections.
8    (a) A registered professional nurse may object to or
9refuse to participate in any activity, practice, assignment,
10or task if:
11        (1) in good faith, the nurse reasonably believes it to
12    be a violation of the direct care registered professional
13    nurse-to-patient ratios established under this Act; or
14        (2) the nurse is not prepared by education, training,
15    or experience to fulfill the assignment without
16    compromising the safety of any patient or jeopardizing the
17    license of the nurse.
18    (b) A facility shall not retaliate, discriminate, or
19otherwise take adverse action in any manner with respect to
20any aspect of a nurse's employment, including discharge,
21promotion, compensation, or terms, conditions, or privileges
22of employment, based on the nurse's refusal to complete an
23assignment under subsection (a).
24    (c) A facility shall not file a complaint against a
25registered professional nurse with the Board of Nursing based



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1on the nurse's refusal to complete an assignment under
2subsection (a).
3    (d) A facility shall not retaliate, discriminate, or
4otherwise take adverse action in any manner against any person
5or with respect to any aspect of a nurse's employment,
6including discharge, promotion, compensation, or terms,
7conditions, or privileges of employment, based on that nurse's
8or that person's opposition to any hospital policy, practice,
9or action that the nurse in good faith believes violates this
11    (e) A facility shall not retaliate, discriminate, or
12otherwise take adverse action against any patient or employee
13of the facility or any other individual on the basis that the
14patient, employee, or individual, in good faith, individually
15or in conjunction with another person or persons, has
16presented a grievance or complaint, or has initiated or
17cooperated in any investigation or proceeding of any
18governmental entity, regulatory agency, or private
19accreditation body, made a civil claim or demand, or filed an
20action relating to the care, services, or conditions of the
21facility or of any affiliated or related facilities.
22    (f) A facility shall not do either of the following:
23        (1) Interfere with, restrain, or deny the exercise of,
24    or attempt to deny the exercise of, a right conferred
25    under this Act.
26        (2) Coerce or intimidate any individual regarding the



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1    exercise of, or an attempt to exercise, a right conferred
2    by this Act.
3    Section 60. Severability. The provisions of this Act are
4severable, and if any clause, sentence, paragraph, subsection,
5or Section of this law or any application thereof shall be
6adjudged by any court of competent jurisdiction to be invalid,
7such judgment shall not affect, impair, or invalidate the
8remainder thereof but shall be confined in its operation to
9the clause, sentence, paragraph, subsection, Section, or
10application adjudged invalid and such clause, sentence,
11paragraph, subsection, Section, or application shall be
12reformed and construed so that it would be valid to the maximum
13extent permitted.
14    Section 85. The Hospital Licensing Act is amended by
15changing Section 10.10 as follows:
16    (210 ILCS 85/10.10)
17    Sec. 10.10. Nurse Staffing by Patient Acuity.
18    (a) Findings. The Legislature finds and declares all of
19the following:
20        (1) The State of Illinois has a substantial interest
21    in promoting quality care and improving the delivery of
22    health care services.
23        (2) Evidence-based studies have shown that the basic



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1    principles of staffing in the acute care setting should be
2    based on the complexity of patients' care needs aligned
3    with available nursing skills to promote quality patient
4    care consistent with professional nursing standards.
5        (3) Compliance with this Section promotes an
6    organizational climate that values registered nurses'
7    input in meeting the health care needs of hospital
8    patients.
9    (b) Definitions. As used in this Section:
10    "Acuity model" means an assessment tool selected and
11implemented by a hospital, as recommended by a nursing care
12committee, that assesses the complexity of patient care needs
13requiring professional nursing care and skills and aligns
14patient care needs and nursing skills consistent with
15professional nursing standards.
16    "Department" means the Department of Public Health.
17    "Direct patient care" means care provided by a registered
18professional nurse with direct responsibility to oversee or
19carry out medical regimens or nursing care for one or more
21    "Nursing care committee" means an existing or newly
22created hospital-wide committee or committees of nurses whose
23functions, in part or in whole, contribute to the development,
24recommendation, and review of the hospital's nurse staffing
25plan established pursuant to subsection (d).
26    "Registered professional nurse" means a person licensed as



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1a Registered Nurse under the Nurse Practice Act.
2    "Written staffing plan for nursing care services" means a
3written plan for guiding the assignment of patient care
4nursing staff based on multiple nurse and patient
5considerations that yield minimum staffing levels for
6inpatient care units and the adopted acuity model aligning
7patient care needs with nursing skills required for quality
8patient care consistent with professional nursing standards.
9    (c) Written staffing plan.
10        (1) Every hospital shall implement a written
11    hospital-wide staffing plan, recommended by a nursing care
12    committee or committees, that provides for minimum direct
13    care professional registered nurse-to-patient staffing
14    needs for each inpatient care unit. The written
15    hospital-wide staffing plan shall include, but need not be
16    limited to, the following considerations:
17            (A) The complexity of complete care, assessment on
18        patient admission, volume of patient admissions,
19        discharges and transfers, evaluation of the progress
20        of a patient's problems, ongoing physical assessments,
21        planning for a patient's discharge, assessment after a
22        change in patient condition, and assessment of the
23        need for patient referrals.
24            (B) The complexity of clinical professional
25        nursing judgment needed to design and implement a
26        patient's nursing care plan, the need for specialized



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1        equipment and technology, the skill mix of other
2        personnel providing or supporting direct patient care,
3        and involvement in quality improvement activities,
4        professional preparation, and experience.
5            (C) Patient acuity and the number of patients for
6        whom care is being provided.
7            (D) The ongoing assessments of a unit's patient
8        acuity levels and nursing staff needed shall be
9        routinely made by the unit nurse manager or his or her
10        designee.
11            (E) The identification of additional registered
12        nurses available for direct patient care when
13        patients' unexpected needs exceed the planned workload
14        for direct care staff.
15        (2) In order to provide staffing flexibility to meet
16    patient needs, every hospital shall identify an acuity
17    model for adjusting the staffing plan for each inpatient
18    care unit.
19        (3) The written staffing plan shall be posted in a
20    conspicuous and accessible location for both patients and
21    direct care staff, as required under the Hospital Report
22    Card Act. A copy of the written staffing plan shall be
23    provided to any member of the general public upon request.
24    (d) Nursing care committee.
25        (1) Every hospital shall have a nursing care
26    committee. A hospital shall appoint members of a committee



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1    whereby at least 50% of the members are registered
2    professional nurses providing direct patient care.
3        (2) A nursing care committee's recommendations must be
4    given significant regard and weight in the hospital's
5    adoption and implementation of a written staffing plan.
6        (3) A nursing care committee or committees shall
7    recommend a written staffing plan for the hospital based
8    on the principles from the staffing components set forth
9    in subsection (c). In particular, a committee or
10    committees shall provide input and feedback on the
11    following:
12            (A) Selection, implementation, and evaluation of
13        minimum staffing levels for inpatient care units.
14            (B) Selection, implementation, and evaluation of
15        an acuity model to provide staffing flexibility that
16        aligns changing patient acuity with nursing skills
17        required.
18            (C) Selection, implementation, and evaluation of a
19        written staffing plan incorporating the items
20        described in subdivisions (c)(1) and (c)(2) of this
21        Section.
22            (D) Review the following: nurse-to-patient
23        staffing guidelines for all inpatient areas; and
24        current acuity tools and measures in use.
25        (4) A nursing care committee must address the items
26    described in subparagraphs (A) through (D) of paragraph



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1    (3) semi-annually.
2    (e) Nothing in this Section 10.10 shall be construed to
3limit, alter, or modify any of the terms, conditions, or
4provisions of a collective bargaining agreement entered into
5by the hospital.
6    (f) Delegation of nursing interventions by a registered
7professional nurse must be in accordance with Section 50-75 of
8the Nurse Practice Act.
9    (g) A hospital shall not mandate that a registered
10professional nurse delegate a nursing intervention, including,
11but not limited to, medication administration, nursing
12judgment, comprehensive patient assessment, development of the
13plan of care, or evaluation of care. A delegation of a nursing
14intervention granted by a registered professional nurse shall
15not be re-delegated to another.
16(Source: P.A. 96-328, eff. 8-11-09; 97-423, eff. 1-1-12;
1797-813, eff. 7-13-12.)
18    Section 90. The Nurse Practice Act is amended by adding
19Section 50-15.15 as follows:
20    (225 ILCS 65/50-15.15 new)
21    Sec. 50-15.15. Clinical professional judgment.
22    (a) Performance of the scope of practice of a direct care
23registered professional nurse requires the exercise of
24professional judgment in the exclusive interests of the



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1patient. The exercise of such professional judgment,
2unencumbered by the commercial or revenue-generation
3priorities of a hospital, long term acute care hospital, or
4ambulatory surgical treatment center or other employing entity
5of a direct care registered professional nurse, is necessary
6to ensure safe, therapeutic, effective, and competent
7treatment of patients and is essential to protect the health
8and safety of the people of Illinois.
9    (b) The exercise of professional judgment by a direct care
10registered professional nurse in the performance of the scope
11of practice of the registered professional nurse under Section
1260-35 or the scope of practice of the advanced practice
13registered nurse under Section 65-30 shall be provided in the
14exclusive interests of the patient and shall not, for any
15purpose, be considered, relied upon, or represented as a job
16function, authority, responsibility, or activity undertaken in
17any respect for the purpose of serving the business,
18commercial, operational, or other institutional interests of
19the employer.
20    (c) No hospital, long term acute care hospital, ambulatory
21surgical treatment center, or other health care institution
22shall adopt policies that:
23        (1) limit a direct care registered professional nurse
24    in performing duties that are part of the nursing process,
25    including full exercise of professional judgment in
26    assessment, planning, implementation and evaluation of



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1    care; or
2        (2) limit a direct care registered professional nurse
3    in acting as a patient advocate in the exclusive interests
4    of the patient.



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2 Statutes amended in order of appearance
3    New Act
4    210 ILCS 85/10.10
5    225 ILCS 65/50-15.15 new