| 1 | 1 | | THE SENATE S.B. NO. 424 THIRTY-THIRD LEGISLATURE, 2025 STATE OF HAWAII A BILL FOR AN ACT Relating to Labor standards at health care facilities. BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII: |
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| 3 | 3 | | THE SENATE S.B. NO. 424 |
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| 4 | 4 | | THIRTY-THIRD LEGISLATURE, 2025 |
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| 5 | 5 | | STATE OF HAWAII |
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| 7 | 7 | | THE SENATE |
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| 9 | 9 | | S.B. NO. |
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| 11 | 11 | | 424 |
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| 13 | 13 | | THIRTY-THIRD LEGISLATURE, 2025 |
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| 17 | 17 | | STATE OF HAWAII |
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| 31 | 31 | | A BILL FOR AN ACT |
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| 37 | 37 | | Relating to Labor standards at health care facilities. |
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| 43 | 43 | | BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII: |
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| 47 | 47 | | SECTION 1. The legislature finds that the health and safety of the State's residents depend on ensuring that registered nurses are supported in providing high-quality, patient-centered care. Adequate patient-nurse staffing ratios are critical to achieving this goal, as they directly impact patient safety, reduce nurse burnout, and promote nurse retention in the workforce. The legislature recognizes that improving patient-to-nurse ratios leads to better patient outcomes, enhanced care quality, and a more sustainable health care system. By establishing minimum patient-to-nurse staffing ratios and requiring hospitals to implement and adhere to enforceable staffing plans, the State can protect its health care workforce, reduce turnover, and ensure that patients receive the safe, timely care they deserve. Accordingly, the purpose of this Act is to: (1) Establish minimum registered nurse staffing standards for hospitals; (2) Require hospitals to create a hospital registered nurse staffing committee; and (3) Appropriate funds to the department of labor and industrial relations to enforce these requirements. SECTION 2. The Hawaii Revised Statutes is amended by adding a new chapter to be appropriately designated and to read as follows: "Chapter Minimum registered nurse staffing standards for health care facilities part I. General Provisions § -1 Definitions. As used in this chapter: "Acuity" means the level of patient need for nursing care, as determined by a nursing assessment. "Charge nurse" means a registered nurse who coordinates patient care responsibilities among nurses in a hospital. "Department" means the department of labor and industrial relations. "Director" means the director of labor and industrial relations. "Hospital" means a hospital regulated by the department of health pursuant to sections 321-11(10) and 321-14.5. "Hospital registered nurse staffing committee" or "staffing committee" means the committee established by a hospital pursuant to section ‑21. "Hospital registered nurse staffing plan" or staffing plan" means the staffing plan for registered nurses developed by a hospital registered nurse staffing committee pursuant to section -22. "Minimum registered nurse staffing standards" means the minimum staffing standards for registered nurses established pursuant to section -11. "Nurse aide" means a "nurse aide", as defined in section 457A-1.5, who provides direct care to patients. "Patient-care unit" means any unit or area of a hospital that provides patient care. "Reasonable efforts to obtain and retain staffing" means to: (1) Seek individuals to volunteer to work extra time from all available qualified staff who are working; (2) Contact qualified employees who have made themselves available to work extra time; (3) Seek the use of per diem staff; and (4) Seek personnel from a contracted temporary agency: (A) To the extent the staffing is permitted by law or an applicable collective bargaining agreement; and (B) When the hospital regularly uses a contracted temporary agency. "Registered nurse" means a "nurse", as defined in section 457-2 or who engages in practices described in section 457-2.5, and provides direct care to patients. "Skill mix" means the experience of, and number and relative percentages of, nursing and ancillary health personnel. "Unforeseeable emergent circumstances" means: (1) Any unforeseen national, state, or county emergency; or (2) When a hospital's disaster plan is activated. § -2 Rules. The department shall adopt rules pursuant to chapter 91 to effectuate the purposes of this chapter. part II. Minimum Staffing Standards § -11 Minimum registered nurse staffing standards. (a) A hospital shall comply with the minimum registered nurse staffing standards established in this section; provided that the charge nurse shall not be included as part of the patient‑to-nurse staffing ratio. (b) A registered nurse shall not be assigned more patients than the following for any shift: (1) For an emergency department: (A) One registered nurse to not more than one trauma or critical care patient; (B) One registered nurse to not more than five patients at one time; and (C) The ratio of registered nurses to patients shall average not more than one to four over a twelve‑hour shift; (2) For an intensive care unit, such as a critical care unit, special care unit, coronary care unit, pediatric intensive care, neonatal intensive care, neurological critical care unit, or burn unit: One registered nurse to one or two patients, depending on the stability of the patient as assessed by the registered nurse on the unit; (3) For labor and delivery: One registered nurse to not more than: (A) Two patients if the patients are not in active labor or experiencing complications; or (B) One patient if the patient is in active labor or is at any stage of labor and is experiencing complications; (4) For postpartum, antepartum, and well-baby nursery: One registered nurse to six patients in postpartum, antepartum, and well-baby nursery; provided that each mother and baby shall be counted as separate patients for the purposes of this paragraph; (5) For an operating room: One registered nurse to one patient; (6) For oncology: One registered nurse to three patients; (7) For a post-anesthesia care unit: One registered nurse to two patients; (8) For a progressive care unit, intermediate specialty care unit, or step down unit: One registered nurse to three patients; (9) For a medical-surgical unit: One registered nurse to four patients; (10) For a telemetry unit: One registered nurse to three patients; (11) For a psychiatric unit: One registered nurse to four patients; provided that staffing ratios may be adjusted as needed based on high patient acuity including patients: (A) Requiring one-on-one observation; (B) In an acute-manic phase; (C) Who are volatile; or (D) Who are physically compromised; (12) For pediatrics: One registered nurse to three patients; and (13) For inpatient hemodialysis: One registered nurse to one patient. (c) The staffing standards established in this section: (1) Are based on the type of care provided in these patient-care units, regardless of the specific name or reference used by the hospital for these units; and (2) Represent the maximum number of patients a registered nurse may be assigned at any time during a shift. (d) A hospital shall not average the number of patients or the total number of registered nurses assigned to patients in a patient-care unit during any one shift or over any period of time to meet the personnel assignment limits established in this section. (e) Nothing in this section precludes a hospital from assigning fewer patients to registered nurses than the limits established in this section. A hospital shall not reduce the current ratio of nurse aides to patients based on the ratios in this section or any collective bargaining agreement. (f) The staffing standards established in this section shall not reduce a hospital's existing patient-to-registered nurse staffing levels: (1) In effect pursuant to a collective bargaining agreement; or (2) Established under a hospital's staffing plan, except pursuant to a majority vote of the hospital registered nurse staffing committee. (g) A registered nurse shall not be assigned to a patient‑care unit or clinical area unless the registered nurse received an orientation in that clinical area sufficient to provide competent care to patients in that area and has demonstrated current competence in providing care in that area. (h) The department shall enforce this section pursuant to section -28 or part IV of this chapter, as appropriate. § -12 Variances. (a) The department may grant a variance from the minimum registered nurse staffing standards if the department determines there is good cause. For purposes of this subsection, "good cause" means situations where a hospital can establish that compliance with the minimum registered nurse staffing standards is not feasible, and that granting a variance does not have a significant harmful effect on the health, safety, and welfare of the involved employees and patients. (b) A hospital may seek a variance from the minimum registered nurse staffing standards by submitting a written application to the department. The application shall contain: (1) A justification that establishes good cause for the variance and noncompliance with the minimum registered nurse staffing standards; (2) The alternative minimum registered nurse staffing standards that will be imposed; (3) The group of employees for whom the variance is sought; (4) Evidence that infeasibility, along with underlying data supporting the claim of infeasibility, were reviewed and discussed at least twice by the hospitals registered nurse staffing committee and a statement from the staffing committee describing the matters for which consensus exists and matters for which there is dispute; and (5) Evidence that the hospital, no later than ten working days before the filing of its request for a variance, provided to the involved employees and, if applicable, their union representatives: (A) A copy of the written request for a variance; (B) Information about the right of the involved employees and, if applicable, their union representatives, to be heard by the department during the variance application review process; (C) Information about the process by which involved employees and, if applicable, their union representatives, may make a written request to the director for reconsideration, subject to the provisions established in subsection (g); and (D) The department's address and phone number, or other contact information. (c) The department shall allow the hospital, any involved employees and, if applicable, their union representatives, the opportunity for oral or written presentation during the variance application review process whenever circumstances of the application warrant it. (d) No later than fifteen days after the date on which the department received the application for a variance, the department shall issue a written decision either granting or denying the variance. The department may extend the fifteen-day time period by providing advance written notice to the hospital and, if applicable, the union representatives of any involved employees, setting forth a reasonable justification for an extension of the fifteen-day time period and the specific duration of the extension; provided that the extension shall not be more than an additional fifteen days. The hospital shall provide involved employees with notice of any extension. (e) A variance shall be granted if the department determines that there is good cause for allowing a hospital to not comply with the minimum registered nurse staffing standards. The variance order shall state: (1) The alternative minimum registered nurse staffing standards approved; (2) The basis for a finding of good cause; (3) The group of employees impacted; and (4) The period of time for which the variance will be valid; provided that the validity period shall not exceed thirty days from the date of issuance. (f) The department shall issue its decision in writing. If the variance is granted, the department shall provide a notification in writing to the hospital and, if applicable, the union representatives of the involved employees. If the variance is denied, the written notification shall include a stated basis for the denial. (g) A hospital, involved employees, and, if applicable, their union representative, may file with the director a request for reconsideration of the department's decision within five days after receiving notice of the variance determination. The request for reconsideration shall set forth the grounds upon which the request is being made. If reasonable grounds exist, the director may grant a review and, to the extent deemed appropriate, afford all interested parties an opportunity to be heard; provided that the written decision of the department shall remain in effect until the reconsideration process is complete. The department shall issue its decision in writing no later than ten days after the date the request for reconsideration was filed with the department. (h) Unless subject to the reconsideration process, the director may revoke or terminate the variance order at any time after giving the hospital at least five-days notice before revoking or terminating the order. (i) Where immediate variance from the minimum registered nurse staffing standards is necessary, the department may issue a temporary variance that shall remain valid until the department determines whether good cause exists for issuing a variance. A hospital need not meet the requirement in subsection (b)(4) to be granted a temporary variance. If a temporary variance is granted, the department shall issue a temporary variance order no later than fifteen days after the date the variance application was filed pursuant to subsection (d). The duration of the temporary variance shall be counted towards the thirty‑day variance period provided in subsection (e)(4). No extension of a temporary variance shall be permitted. (j) If a hospital obtains a variance under this section, the hospital shall inform involved employees about the minimum registered nurse staffing standards that apply within five days of receiving notification of the variance approval from the department. A hospital shall make this information readily available to all employees. (k) The director may adopt rules to establish additional variance eligibility criteria. part III. Registered Nurse Staffing Plan for Hospitals § -21 Hospital registered nurse staffing committee; membership; quorum. (a) No later than September 1, 2025, each hospital shall establish a hospital registered nurse staffing committee. (b) A majority of the members of the staffing committee shall be nonsupervisory, nonmanagerial, registered nurses currently providing direct patient care, who shall be appointed by the collective bargaining representative or representatives of the registered nurses; provided that if there is no collective bargaining representative, these members shall be selected by their peers. (c) The remainder of the members of the staffing committee shall be selected by the hospital administration; provided that these members shall include the chief financial officer, chief nursing officer, and patient-care unit directors or managers, or their designees. (d) A staffing committee shall have two co-chairs. One co-chair shall be selected from the registered nurse members of the staffing committee. The other co-chair shall be selected from the members selected by the hospital administration. (e) A majority of the members of the staffing committee shall constitute a quorum for the transaction of business. The staffing committee may act by a majority vote of the members present and voting at a meeting at which there is quorum; provided that any vote taken shall be void unless the number of members who are registered nurses present and voting exceeds the number of members selected by the hospital administration present and voting. (f) Participation in the staffing committee by a hospital employee shall be on scheduled work time and compensated at the appropriate rate of pay. Staffing committee members shall be relieved of all other work duties during meetings of the staffing committee. Additional staffing relief shall be provided if necessary to ensure that staffing committee members are able to attend the staffing committee meetings. § -22 Hospital registered nurse staffing plan; committee responsibilities. (a) The primary responsibilities of the staffing committee shall include: (1) Development and oversight of an annual patient-care unit and shift-based hospital registered nurse staffing plan in accordance with the minimum registered nurse staffing standards based on the needs of patients, to be used as the primary means to ensure that the hospital is staffed sufficiently to meet the health care needs and safety for all patients and health care providers. The staffing committee shall use a uniform format or form, created by the department in consultation with stakeholders from hospitals and labor organizations, for complying with the requirement to submit the annual staffing plan. The uniform format or form shall provide space to include the factors considered under this section and allow patients and the public to clearly understand and compare staffing patterns and actual levels of staffing across facilities. Hospitals may include a description of additional resources available to support unit-level patient care and a description of the hospital, including the size and type of facility. Factors to be considered in the development of the plan shall include: (A) Census, including total numbers of patients on the unit on each shift and activity, including patient discharges, admissions, and transfers; (B) Level of acuity of all patients and nature of the care to be delivered on each shift and patient type; (C) Skill mix; (D) Level of experience and specialty certification or training of nursing personnel providing care; (E) National standards, if any; (F) Patient access to care; (G) The need for specialized or intensive equipment; (H) The architecture and geography of the patient‑care unit, including but not limited to placement of patient rooms, treatment areas, nursing stations, medication preparation areas, and equipment; (I) Availability of non-registered nurse personnel supporting nursing services on the unit; and (J) Ability to comply with the terms of an applicable collective bargaining agreement, if any, and relevant state and federal laws and rules, including those regarding meals and rest breaks and use of overtime and on-call shifts; (2) Semiannual review of the hospital registered nurse staffing plan against the ability to meet the minimum registered nurse staffing standards, patient need, and known evidence-based staffing information, including the nursing sensitive quality indicators collected by the hospital; and (3) Review, assessment, and response to staffing variations or complaints presented to the staffing committee. (b) In addition to the factors listed in subsection (a)(1), hospital finances and resources should be taken into account in the development of the hospital registered nurse staffing plan. (c) The hospital registered nurse staffing plan shall not diminish other standards contained in state or federal law and rules or the terms of an applicable collective bargaining agreement. (d) The staffing committee shall review the hospital registered nurse staffing plan on a semiannual basis and develop and adopt a written hospital registered nurse staffing plan, including a patient-care and unit-based registered nurse staffing plan, on an annual basis. If the staffing committee fails to adopt a staffing plan, the prior annual staffing plan shall remain in effect and the hospital shall be subject to a daily fine of $5,000 until the staffing committee adopts a new annual staffing plan by majority vote; provided that the following hospitals shall be subject to a daily fine of $100 until their staffing committee adopts a new annual staffing plan by majority vote: (1) Hospitals certified as a critical access hospital; (2) Hospitals having fewer than twenty-five acute care beds in operation; and (3) Hospitals certified by the federal Centers for Medicare and Medicaid Services as a sole community hospital that: (A) Has fewer than one hundred acute care licensed beds; (B) Has a level III adult trauma service designation from the department of health; and (C) Is owned and operated by the State. (e) The chief executive officer of a hospital shall submit a report to the hospital registered nurse staffing committee on a semiannual basis, before the staffing committee's semiannual review and adoption of an annual staffing plan. The report shall: (1) Identify elements of the staffing plan the chief executive officer requests changes to, if any; and (2) Provide a status of the implementation of the staffing plan, including nursing sensitive quality indicators collected by the hospital, patient surveys, and recruitment and retention efforts. (f) Beginning July 1, 2026, each hospital shall submit its hospital registered nurse staffing plan to the department. Thereafter, each hospital shall submit its staffing plan to the department on an annual basis and at any time that the staffing plan is updated. § -23 Implementation; complaints. (a) Beginning July 1, 2026, each hospital shall implement a hospital registered nurse staffing plan and assign personnel to each patient-care unit in accordance with the plan. (b) A registered nurse, collective bargaining representative if applicable, patient, or any other person may report to or file a complaint with the staffing committee any registered nurse assignment in a patient-care unit that deviates from the hospital registered nurse staffing plan in effect. (c) Shift-to-shift adjustments in registered nurse staffing levels required by the staffing plan may be made by the appropriate hospital personnel overseeing patient-care operations. If a person who is covered by a hospital registered nurse staffing plan on a patient-care unit objects to a shift‑to-shift adjustment, the person may file a complaint with the staffing committee. (d) The staffing committee shall develop a process to examine and respond to reports and complaints submitted pursuant to subsections (b) and (c), including the criteria and information needed to determine if a specific complaint is resolved or should be dismissed based on unsubstantiated information. The staffing committee shall review all reports and complaints received, regardless of the format of the report or complaint. § -24 Notice. Each hospital shall post, in a public area on each patient-care unit, the hospital registered nurse staffing plan and the staffing schedule for the shift of that unit, and the relevant clinical staffing for that shift. The staffing plan and current staffing levels shall also be made available to patients and visitors upon request. § -25 Retaliation prohibited. No hospital shall discipline, take any adverse employment action, or otherwise retaliate against or engage in any form of intimidation towards: (1) A registered nurse for performing any duties or responsibilities in connection with the staffing committee; (2) A registered nurse, patient, or other individual who notifies the staffing committee or the hospital administration of that person's concerns on the staffing of registered nurses; or (3) A registered nurse who refuses to work overtime. § -26 Critical access hospitals. Nothing in this part shall be construed to create unreasonable burdens on critical access hospitals under title 42 United States Code section 1395i4. Critical access hospitals may develop flexible approaches to accomplish the requirements of this part, including but not limited to having their hospital registered nurse staffing committees work by video conference, telephone, or email. § -27 Charter; filing requirements. The staffing committee shall file with the department a hospital registered nurse staffing committee charter that shall include: (1) Roles, responsibilities, and processes by which the staffing committee functions, including processes to ensure adequate quorum and attendance of staffing committee members, including giving them notice at least thirty days before a meeting; (2) A schedule for at least one meeting per month, with more frequent meetings as needed; (3) Processes by which all registered nurse staffing complaints will be reviewed, noting the date received as well as initial, contingent, and final disposition of complaints and corrective action plan where applicable; (4) Processes by which complaints will be resolved within ninety days of receipt, or longer with a majority approval of the staffing committee, and processes to ensure the complainant receives a letter stating the outcome of the complaint; (5) Processes for attendance by any employee, and a labor representative if requested by the employee, who is involved in a complaint; (6) Processes for the staffing committee to conduct quarterly reviews of registered nurse turnover rates, including new hire turnover rates during the first year of employment and hospital plans regarding workforce development; (7) Standards for the staffing committee's approval of meeting documentation, including meeting minutes, attendance, and actions taken; and (8) Policies for retention of meeting documentation for a minimum of three years; provided that the policy shall be consistent with each hospital's document retention policies. § -28 Department investigations. (a) The department shall investigate a complaint submitted under this section for alleged violations of this part following receipt of a complaint with documented evidence of a hospital's failure to: (1) Establish a hospital registered nurse staffing committee; (2) Conduct a semiannual review of its hospital registered nurse staffing plan; (3) Submit to the department its hospital registered nurse staffing plan on an annual basis and upon any updates; or (4) Assign registered nurses in a patient-care unit in compliance with section 11 or 23(a), or shift‑to-shift adjustments in registered nurse staffing levels in compliance with section 23(c). (b) If the department determines after an investigation conducted pursuant to subsection (a) that there has been a violation, the department shall require the hospital to submit a corrective plan of action within thirty days of the presentation of findings from the department to the hospital. (c) Hospitals shall not be found in violation of section -11 or 23(a) if the department determines, following an investigation, that: (1) There were unforeseeable emergent circumstances; or (2) The hospital, after consultation with its staffing committee, documents that the hospital has made reasonable efforts to obtain and retain staffing to meet the required registered nurse staffing assignments but has been unable to do so. (d) No later than thirty days after a hospital deviates from its hospital registered nurse staffing plan as adopted by its staffing committee, the hospital administration shall report to the staffing committee an assessment of the registered nurse staffing needs arising from the unforeseeable emergent circumstance and the hospital's plan to address those identified staffing needs. Upon receipt of the report, the staffing committee shall convene to develop a contingency staffing plan to address the needs arising from the unforeseeable emergent circumstance. The hospital's deviation from its staffing plan may not be in effect for more than thirty days without the approval of the staffing committee. (e) If a hospital fails to submit, or submits but fails to follow, a corrective plan of action in response to a violation or violations found by the department based on a complaint filed pursuant to subsection (a), the department may impose, for all violations asserted against a hospital at any time, a civil penalty of $5,000 per day; provided that the fine shall be $100 per day for hospitals: (1) Certified as a critical access hospital; (2) Having fewer than twentyfive acute care beds in operation; and (3) Certified by the federal Centers for Medicare and Medicaid services as a sole community hospital that: (A) Has less than one hundred fifty acute care licensed beds; (B) Has a level III adult trauma service designation from the department of health; and (C) Is owned and operated by the State. Civil penalties shall continue to apply until the hospital submits a corrective plan of action that has been approved by the department and follows the corrective plan of action for ninety days. Once the approved corrective action plan has been followed by the hospital for ninety days, the department may reduce the accumulated fine. The fine shall continue to accumulate until the ninety days have passed. (f) The department shall: (1) Maintain for public inspection records of any civil penalties and administrative actions imposed on hospitals under this section; and (2) Report violations of this chapter on its website. (g) Nothing in this chapter shall be construed to preclude the ability to otherwise submit a complaint to the department for failure to follow this chapter. § -29 Review of staffing plans by the department. (a) The department shall review each hospital registered nurse staffing plan submitted by a hospital to ensure submittal by the applicable deadline in the form prescribed by the department. (b) A hospital shall complete all portions of the hospital registered nurse staffing plan form prescribed by the department. The department may determine that a hospital has failed to timely submit its staffing plan if the staffing plan form is incomplete. (c) Failure to submit the hospital registered nurse staffing plan or hospital registered nurse staffing committee charter by the applicable deadline shall be a violation and shall be punishable by a civil penalty of $25,000 issued by the department. (d) The department shall post on its website: (1) Hospital registered nurse staffing plans received by the department; (2) Hospital registered nurse staffing committee charters received by the department; and (3) Violations of this section. part IV. Complaints § -31 Complaints. (a) If a complainant files a complaint with the department alleging a violation of this chapter, the department shall investigate the complaint; provided that nothing in this part shall prohibit the department from taking any other enforcement action authorized elsewhere in this chapter or pursuant to any other law. (b) The department shall not investigate any alleged violation of rights that occurred more than sixty days before the date on which the complainant filed the complaint. (c) Upon the investigation of a complaint, the department shall issue either a citation and notice of assessment or a closure letter, within ninety days after the date the department received the complaint, unless the complaint is otherwise resolved. The department may extend the ninety-day period by providing advance written notice to the complainant and the hospital setting forth good cause for the extension and the specific duration of the extension. (d) The department shall send a citation and notice of assessment or the closure letter to both the hospital and the complainant by service of process or another method that allows the delivery to the complainant's last known addresses to be tracked and confirmed. (e) If the department's investigation finds that the complainant's allegation cannot be substantiated, the department shall issue a closure letter to the complainant and the hospital detailing that finding. (f) Any hospital found by the department to be in violation of this chapter shall be subject to: (1) A fine not to exceed $1,000 for each of the first three violations; (2) $2,500 for the fourth violation; and (3) $5,000 for the fifth and each subsequent violation. (g) At any time, the department may waive or reduce a civil penalty assessed under this section if the director determines that the hospital has taken corrective action to resolve the violation. § -32 Appeals. (a) A person aggrieved by a citation and notice of assessment by the department under this chapter may appeal the citation and notice of assessment by filing a notice of appeal with the director within thirty days of the department's issuance of the citation and notice of assessment. A citation and notice of assessment not appealed within thirty days is final and binding, and shall not be subject to further appeal. (b) A notice of appeal filed with the director under this section shall stay the citation and notice of assessment pending final review of the appeal by the director. (c) Upon receipt of a notice of appeal, the director shall assign the matter to a hearings officer to hold a hearing and issue an initial order. The appeal process shall be conducted in accordance with chapter 91, and the standard of review by the hearings officer of an appealed citation and notice of assessment shall be de novo. Any party who seeks to challenge an initial order shall file a petition for administrative review with the director within thirty days after service of the initial order. The director shall conduct administrative review in accordance with chapter 91. (d) The director shall issue all final orders after appeal of the initial order. The final order of the director is subject to judicial review in accordance with chapter 91. (e) Orders that are not appealed within the time period specified in this section and chapter 91 are final and binding and not subject to further appeal. (f) A hospital that fails to allow adequate inspection of records in an investigation by the department under this chapter within a reasonable time period may not use those records in any appeal under this section to challenge the correctness of any determination by the department of the penalty assessed." SECTION 3. There is appropriated out of the general revenues of the State of Hawaii the sum of $ or so much thereof as may be necessary for fiscal year 2025-2026 and the same sum or so much thereof as may be necessary for fiscal year 2026-2027 to implement and enforce section 2 of this Act. The sums appropriated shall be expended by the department of labor and industrial relations for the purposes of this Act. SECTION 4. This Act does not affect rights and duties that matured, penalties that were incurred, and proceedings that were begun before its effective date. SECTION 5. This Act shall take effect upon its approval; provided that section 3 shall take effect on July 1, 2025. INTRODUCED BY: _____________________________ |
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| 49 | 49 | | SECTION 1. The legislature finds that the health and safety of the State's residents depend on ensuring that registered nurses are supported in providing high-quality, patient-centered care. Adequate patient-nurse staffing ratios are critical to achieving this goal, as they directly impact patient safety, reduce nurse burnout, and promote nurse retention in the workforce. The legislature recognizes that improving patient-to-nurse ratios leads to better patient outcomes, enhanced care quality, and a more sustainable health care system. By establishing minimum patient-to-nurse staffing ratios and requiring hospitals to implement and adhere to enforceable staffing plans, the State can protect its health care workforce, reduce turnover, and ensure that patients receive the safe, timely care they deserve. |
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| 51 | 51 | | Accordingly, the purpose of this Act is to: |
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| 52 | 52 | | |
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| 53 | 53 | | (1) Establish minimum registered nurse staffing standards for hospitals; |
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| 55 | 55 | | (2) Require hospitals to create a hospital registered nurse staffing committee; and |
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| 56 | 56 | | |
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| 57 | 57 | | (3) Appropriate funds to the department of labor and industrial relations to enforce these requirements. |
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| 59 | 59 | | SECTION 2. The Hawaii Revised Statutes is amended by adding a new chapter to be appropriately designated and to read as follows: |
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| 60 | 60 | | |
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| 61 | 61 | | "Chapter |
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| 62 | 62 | | |
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| 63 | 63 | | Minimum registered nurse staffing standards for health care facilities |
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| 64 | 64 | | |
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| 65 | 65 | | part I. General Provisions |
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| 66 | 66 | | |
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| 67 | 67 | | § -1 Definitions. As used in this chapter: |
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| 68 | 68 | | |
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| 69 | 69 | | "Acuity" means the level of patient need for nursing care, as determined by a nursing assessment. |
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| 70 | 70 | | |
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| 71 | 71 | | "Charge nurse" means a registered nurse who coordinates patient care responsibilities among nurses in a hospital. |
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| 72 | 72 | | |
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| 73 | 73 | | "Department" means the department of labor and industrial relations. |
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| 75 | 75 | | "Director" means the director of labor and industrial relations. |
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| 76 | 76 | | |
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| 77 | 77 | | "Hospital" means a hospital regulated by the department of health pursuant to sections 321-11(10) and 321-14.5. |
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| 78 | 78 | | |
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| 79 | 79 | | "Hospital registered nurse staffing committee" or "staffing committee" means the committee established by a hospital pursuant to section ‑21. |
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| 80 | 80 | | |
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| 81 | 81 | | "Hospital registered nurse staffing plan" or staffing plan" means the staffing plan for registered nurses developed by a hospital registered nurse staffing committee pursuant to section -22. |
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| 82 | 82 | | |
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| 83 | 83 | | "Minimum registered nurse staffing standards" means the minimum staffing standards for registered nurses established pursuant to section -11. |
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| 84 | 84 | | |
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| 85 | 85 | | "Nurse aide" means a "nurse aide", as defined in section 457A-1.5, who provides direct care to patients. |
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| 86 | 86 | | |
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| 87 | 87 | | "Patient-care unit" means any unit or area of a hospital that provides patient care. |
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| 88 | 88 | | |
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| 89 | 89 | | "Reasonable efforts to obtain and retain staffing" means to: |
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| 90 | 90 | | |
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| 91 | 91 | | (1) Seek individuals to volunteer to work extra time from all available qualified staff who are working; |
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| 92 | 92 | | |
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| 93 | 93 | | (2) Contact qualified employees who have made themselves available to work extra time; |
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| 94 | 94 | | |
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| 95 | 95 | | (3) Seek the use of per diem staff; and |
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| 96 | 96 | | |
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| 97 | 97 | | (4) Seek personnel from a contracted temporary agency: |
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| 98 | 98 | | |
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| 99 | 99 | | (A) To the extent the staffing is permitted by law or an applicable collective bargaining agreement; and |
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| 100 | 100 | | |
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| 101 | 101 | | (B) When the hospital regularly uses a contracted temporary agency. |
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| 102 | 102 | | |
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| 103 | 103 | | "Registered nurse" means a "nurse", as defined in section 457-2 or who engages in practices described in section 457-2.5, and provides direct care to patients. |
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| 104 | 104 | | |
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| 105 | 105 | | "Skill mix" means the experience of, and number and relative percentages of, nursing and ancillary health personnel. |
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| 106 | 106 | | |
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| 107 | 107 | | "Unforeseeable emergent circumstances" means: |
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| 108 | 108 | | |
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| 109 | 109 | | (1) Any unforeseen national, state, or county emergency; or |
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| 110 | 110 | | |
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| 111 | 111 | | (2) When a hospital's disaster plan is activated. |
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| 112 | 112 | | |
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| 113 | 113 | | § -2 Rules. The department shall adopt rules pursuant to chapter 91 to effectuate the purposes of this chapter. |
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| 114 | 114 | | |
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| 115 | 115 | | part II. Minimum Staffing Standards |
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| 116 | 116 | | |
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| 117 | 117 | | § -11 Minimum registered nurse staffing standards. (a) A hospital shall comply with the minimum registered nurse staffing standards established in this section; provided that the charge nurse shall not be included as part of the patient‑to-nurse staffing ratio. |
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| 118 | 118 | | |
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| 119 | 119 | | (b) A registered nurse shall not be assigned more patients than the following for any shift: |
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| 120 | 120 | | |
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| 121 | 121 | | (1) For an emergency department: |
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| 122 | 122 | | |
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| 123 | 123 | | (A) One registered nurse to not more than one trauma or critical care patient; |
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| 124 | 124 | | |
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| 125 | 125 | | (B) One registered nurse to not more than five patients at one time; and |
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| 126 | 126 | | |
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| 127 | 127 | | (C) The ratio of registered nurses to patients shall average not more than one to four over a twelve‑hour shift; |
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| 128 | 128 | | |
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| 129 | 129 | | (2) For an intensive care unit, such as a critical care unit, special care unit, coronary care unit, pediatric intensive care, neonatal intensive care, neurological critical care unit, or burn unit: One registered nurse to one or two patients, depending on the stability of the patient as assessed by the registered nurse on the unit; |
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| 130 | 130 | | |
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| 131 | 131 | | (3) For labor and delivery: One registered nurse to not more than: |
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| 132 | 132 | | |
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| 133 | 133 | | (A) Two patients if the patients are not in active labor or experiencing complications; or |
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| 134 | 134 | | |
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| 135 | 135 | | (B) One patient if the patient is in active labor or is at any stage of labor and is experiencing complications; |
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| 136 | 136 | | |
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| 137 | 137 | | (4) For postpartum, antepartum, and well-baby nursery: One registered nurse to six patients in postpartum, antepartum, and well-baby nursery; provided that each mother and baby shall be counted as separate patients for the purposes of this paragraph; |
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| 138 | 138 | | |
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| 139 | 139 | | (5) For an operating room: One registered nurse to one patient; |
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| 140 | 140 | | |
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| 141 | 141 | | (6) For oncology: One registered nurse to three patients; |
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| 142 | 142 | | |
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| 143 | 143 | | (7) For a post-anesthesia care unit: One registered nurse to two patients; |
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| 144 | 144 | | |
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| 145 | 145 | | (8) For a progressive care unit, intermediate specialty care unit, or step down unit: One registered nurse to three patients; |
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| 146 | 146 | | |
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| 147 | 147 | | (9) For a medical-surgical unit: One registered nurse to four patients; |
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| 148 | 148 | | |
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| 149 | 149 | | (10) For a telemetry unit: One registered nurse to three patients; |
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| 150 | 150 | | |
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| 151 | 151 | | (11) For a psychiatric unit: One registered nurse to four patients; provided that staffing ratios may be adjusted as needed based on high patient acuity including patients: |
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| 152 | 152 | | |
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| 153 | 153 | | (A) Requiring one-on-one observation; |
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| 154 | 154 | | |
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| 155 | 155 | | (B) In an acute-manic phase; |
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| 156 | 156 | | |
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| 157 | 157 | | (C) Who are volatile; or |
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| 158 | 158 | | |
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| 159 | 159 | | (D) Who are physically compromised; |
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| 160 | 160 | | |
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| 161 | 161 | | (12) For pediatrics: One registered nurse to three patients; and |
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| 162 | 162 | | |
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| 163 | 163 | | (13) For inpatient hemodialysis: One registered nurse to one patient. |
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| 164 | 164 | | |
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| 165 | 165 | | (c) The staffing standards established in this section: |
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| 166 | 166 | | |
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| 167 | 167 | | (1) Are based on the type of care provided in these patient-care units, regardless of the specific name or reference used by the hospital for these units; and |
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| 168 | 168 | | |
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| 169 | 169 | | (2) Represent the maximum number of patients a registered nurse may be assigned at any time during a shift. |
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| 170 | 170 | | |
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| 171 | 171 | | (d) A hospital shall not average the number of patients or the total number of registered nurses assigned to patients in a patient-care unit during any one shift or over any period of time to meet the personnel assignment limits established in this section. |
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| 172 | 172 | | |
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| 173 | 173 | | (e) Nothing in this section precludes a hospital from assigning fewer patients to registered nurses than the limits established in this section. A hospital shall not reduce the current ratio of nurse aides to patients based on the ratios in this section or any collective bargaining agreement. |
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| 174 | 174 | | |
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| 175 | 175 | | (f) The staffing standards established in this section shall not reduce a hospital's existing patient-to-registered nurse staffing levels: |
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| 176 | 176 | | |
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| 177 | 177 | | (1) In effect pursuant to a collective bargaining agreement; or |
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| 178 | 178 | | |
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| 179 | 179 | | (2) Established under a hospital's staffing plan, except pursuant to a majority vote of the hospital registered nurse staffing committee. |
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| 180 | 180 | | |
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| 181 | 181 | | (g) A registered nurse shall not be assigned to a patient‑care unit or clinical area unless the registered nurse received an orientation in that clinical area sufficient to provide competent care to patients in that area and has demonstrated current competence in providing care in that area. |
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| 182 | 182 | | |
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| 183 | 183 | | (h) The department shall enforce this section pursuant to section -28 or part IV of this chapter, as appropriate. |
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| 184 | 184 | | |
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| 185 | 185 | | § -12 Variances. (a) The department may grant a variance from the minimum registered nurse staffing standards if the department determines there is good cause. For purposes of this subsection, "good cause" means situations where a hospital can establish that compliance with the minimum registered nurse staffing standards is not feasible, and that granting a variance does not have a significant harmful effect on the health, safety, and welfare of the involved employees and patients. |
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| 186 | 186 | | |
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| 187 | 187 | | (b) A hospital may seek a variance from the minimum registered nurse staffing standards by submitting a written application to the department. The application shall contain: |
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| 188 | 188 | | |
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| 189 | 189 | | (1) A justification that establishes good cause for the variance and noncompliance with the minimum registered nurse staffing standards; |
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| 190 | 190 | | |
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| 191 | 191 | | (2) The alternative minimum registered nurse staffing standards that will be imposed; |
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| 192 | 192 | | |
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| 193 | 193 | | (3) The group of employees for whom the variance is sought; |
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| 194 | 194 | | |
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| 195 | 195 | | (4) Evidence that infeasibility, along with underlying data supporting the claim of infeasibility, were reviewed and discussed at least twice by the hospitals registered nurse staffing committee and a statement from the staffing committee describing the matters for which consensus exists and matters for which there is dispute; and |
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| 196 | 196 | | |
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| 197 | 197 | | (5) Evidence that the hospital, no later than ten working days before the filing of its request for a variance, provided to the involved employees and, if applicable, their union representatives: |
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| 198 | 198 | | |
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| 199 | 199 | | (A) A copy of the written request for a variance; |
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| 200 | 200 | | |
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| 201 | 201 | | (B) Information about the right of the involved employees and, if applicable, their union representatives, to be heard by the department during the variance application review process; |
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| 202 | 202 | | |
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| 203 | 203 | | (C) Information about the process by which involved employees and, if applicable, their union representatives, may make a written request to the director for reconsideration, subject to the provisions established in subsection (g); and |
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| 204 | 204 | | |
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| 205 | 205 | | (D) The department's address and phone number, or other contact information. |
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| 206 | 206 | | |
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| 207 | 207 | | (c) The department shall allow the hospital, any involved employees and, if applicable, their union representatives, the opportunity for oral or written presentation during the variance application review process whenever circumstances of the application warrant it. |
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| 208 | 208 | | |
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| 209 | 209 | | (d) No later than fifteen days after the date on which the department received the application for a variance, the department shall issue a written decision either granting or denying the variance. The department may extend the fifteen-day time period by providing advance written notice to the hospital and, if applicable, the union representatives of any involved employees, setting forth a reasonable justification for an extension of the fifteen-day time period and the specific duration of the extension; provided that the extension shall not be more than an additional fifteen days. The hospital shall provide involved employees with notice of any extension. |
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| 210 | 210 | | |
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| 211 | 211 | | (e) A variance shall be granted if the department determines that there is good cause for allowing a hospital to not comply with the minimum registered nurse staffing standards. The variance order shall state: |
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| 212 | 212 | | |
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| 213 | 213 | | (1) The alternative minimum registered nurse staffing standards approved; |
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| 214 | 214 | | |
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| 215 | 215 | | (2) The basis for a finding of good cause; |
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| 216 | 216 | | |
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| 217 | 217 | | (3) The group of employees impacted; and |
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| 218 | 218 | | |
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| 219 | 219 | | (4) The period of time for which the variance will be valid; provided that the validity period shall not exceed thirty days from the date of issuance. |
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| 220 | 220 | | |
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| 221 | 221 | | (f) The department shall issue its decision in writing. If the variance is granted, the department shall provide a notification in writing to the hospital and, if applicable, the union representatives of the involved employees. If the variance is denied, the written notification shall include a stated basis for the denial. |
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| 222 | 222 | | |
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| 223 | 223 | | (g) A hospital, involved employees, and, if applicable, their union representative, may file with the director a request for reconsideration of the department's decision within five days after receiving notice of the variance determination. The request for reconsideration shall set forth the grounds upon which the request is being made. If reasonable grounds exist, the director may grant a review and, to the extent deemed appropriate, afford all interested parties an opportunity to be heard; provided that the written decision of the department shall remain in effect until the reconsideration process is complete. The department shall issue its decision in writing no later than ten days after the date the request for reconsideration was filed with the department. |
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| 224 | 224 | | |
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| 225 | 225 | | (h) Unless subject to the reconsideration process, the director may revoke or terminate the variance order at any time after giving the hospital at least five-days notice before revoking or terminating the order. |
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| 226 | 226 | | |
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| 227 | 227 | | (i) Where immediate variance from the minimum registered nurse staffing standards is necessary, the department may issue a temporary variance that shall remain valid until the department determines whether good cause exists for issuing a variance. A hospital need not meet the requirement in subsection (b)(4) to be granted a temporary variance. If a temporary variance is granted, the department shall issue a temporary variance order no later than fifteen days after the date the variance application was filed pursuant to subsection (d). The duration of the temporary variance shall be counted towards the thirty‑day variance period provided in subsection (e)(4). No extension of a temporary variance shall be permitted. |
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| 228 | 228 | | |
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| 229 | 229 | | (j) If a hospital obtains a variance under this section, the hospital shall inform involved employees about the minimum registered nurse staffing standards that apply within five days of receiving notification of the variance approval from the department. A hospital shall make this information readily available to all employees. |
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| 230 | 230 | | |
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| 231 | 231 | | (k) The director may adopt rules to establish additional variance eligibility criteria. |
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| 232 | 232 | | |
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| 233 | 233 | | part III. Registered Nurse Staffing Plan for Hospitals |
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| 234 | 234 | | |
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| 235 | 235 | | § -21 Hospital registered nurse staffing committee; membership; quorum. (a) No later than September 1, 2025, each hospital shall establish a hospital registered nurse staffing committee. |
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| 236 | 236 | | |
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| 237 | 237 | | (b) A majority of the members of the staffing committee shall be nonsupervisory, nonmanagerial, registered nurses currently providing direct patient care, who shall be appointed by the collective bargaining representative or representatives of the registered nurses; provided that if there is no collective bargaining representative, these members shall be selected by their peers. |
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| 238 | 238 | | |
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| 239 | 239 | | (c) The remainder of the members of the staffing committee shall be selected by the hospital administration; provided that these members shall include the chief financial officer, chief nursing officer, and patient-care unit directors or managers, or their designees. |
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| 240 | 240 | | |
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| 241 | 241 | | (d) A staffing committee shall have two co-chairs. One co-chair shall be selected from the registered nurse members of the staffing committee. The other co-chair shall be selected from the members selected by the hospital administration. |
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| 242 | 242 | | |
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| 243 | 243 | | (e) A majority of the members of the staffing committee shall constitute a quorum for the transaction of business. The staffing committee may act by a majority vote of the members present and voting at a meeting at which there is quorum; provided that any vote taken shall be void unless the number of members who are registered nurses present and voting exceeds the number of members selected by the hospital administration present and voting. |
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| 244 | 244 | | |
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| 245 | 245 | | (f) Participation in the staffing committee by a hospital employee shall be on scheduled work time and compensated at the appropriate rate of pay. Staffing committee members shall be relieved of all other work duties during meetings of the staffing committee. Additional staffing relief shall be provided if necessary to ensure that staffing committee members are able to attend the staffing committee meetings. |
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| 246 | 246 | | |
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| 247 | 247 | | § -22 Hospital registered nurse staffing plan; committee responsibilities. (a) The primary responsibilities of the staffing committee shall include: |
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| 248 | 248 | | |
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| 249 | 249 | | (1) Development and oversight of an annual patient-care unit and shift-based hospital registered nurse staffing plan in accordance with the minimum registered nurse staffing standards based on the needs of patients, to be used as the primary means to ensure that the hospital is staffed sufficiently to meet the health care needs and safety for all patients and health care providers. The staffing committee shall use a uniform format or form, created by the department in consultation with stakeholders from hospitals and labor organizations, for complying with the requirement to submit the annual staffing plan. The uniform format or form shall provide space to include the factors considered under this section and allow patients and the public to clearly understand and compare staffing patterns and actual levels of staffing across facilities. Hospitals may include a description of additional resources available to support unit-level patient care and a description of the hospital, including the size and type of facility. Factors to be considered in the development of the plan shall include: |
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| 250 | 250 | | |
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| 251 | 251 | | (A) Census, including total numbers of patients on the unit on each shift and activity, including patient discharges, admissions, and transfers; |
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| 252 | 252 | | |
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| 253 | 253 | | (B) Level of acuity of all patients and nature of the care to be delivered on each shift and patient type; |
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| 254 | 254 | | |
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| 255 | 255 | | (C) Skill mix; |
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| 256 | 256 | | |
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| 257 | 257 | | (D) Level of experience and specialty certification or training of nursing personnel providing care; |
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| 258 | 258 | | |
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| 259 | 259 | | (E) National standards, if any; |
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| 260 | 260 | | |
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| 261 | 261 | | (F) Patient access to care; |
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| 262 | 262 | | |
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| 263 | 263 | | (G) The need for specialized or intensive equipment; |
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| 264 | 264 | | |
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| 265 | 265 | | (H) The architecture and geography of the patient‑care unit, including but not limited to placement of patient rooms, treatment areas, nursing stations, medication preparation areas, and equipment; |
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| 266 | 266 | | |
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| 267 | 267 | | (I) Availability of non-registered nurse personnel supporting nursing services on the unit; and |
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| 268 | 268 | | |
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| 269 | 269 | | (J) Ability to comply with the terms of an applicable collective bargaining agreement, if any, and relevant state and federal laws and rules, including those regarding meals and rest breaks and use of overtime and on-call shifts; |
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| 270 | 270 | | |
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| 271 | 271 | | (2) Semiannual review of the hospital registered nurse staffing plan against the ability to meet the minimum registered nurse staffing standards, patient need, and known evidence-based staffing information, including the nursing sensitive quality indicators collected by the hospital; and |
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| 272 | 272 | | |
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| 273 | 273 | | (3) Review, assessment, and response to staffing variations or complaints presented to the staffing committee. |
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| 274 | 274 | | |
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| 275 | 275 | | (b) In addition to the factors listed in subsection (a)(1), hospital finances and resources should be taken into account in the development of the hospital registered nurse staffing plan. |
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| 276 | 276 | | |
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| 277 | 277 | | (c) The hospital registered nurse staffing plan shall not diminish other standards contained in state or federal law and rules or the terms of an applicable collective bargaining agreement. |
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| 278 | 278 | | |
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| 279 | 279 | | (d) The staffing committee shall review the hospital registered nurse staffing plan on a semiannual basis and develop and adopt a written hospital registered nurse staffing plan, including a patient-care and unit-based registered nurse staffing plan, on an annual basis. If the staffing committee fails to adopt a staffing plan, the prior annual staffing plan shall remain in effect and the hospital shall be subject to a daily fine of $5,000 until the staffing committee adopts a new annual staffing plan by majority vote; provided that the following hospitals shall be subject to a daily fine of $100 until their staffing committee adopts a new annual staffing plan by majority vote: |
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| 280 | 280 | | |
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| 281 | 281 | | (1) Hospitals certified as a critical access hospital; |
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| 282 | 282 | | |
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| 283 | 283 | | (2) Hospitals having fewer than twenty-five acute care beds in operation; and |
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| 284 | 284 | | |
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| 285 | 285 | | (3) Hospitals certified by the federal Centers for Medicare and Medicaid Services as a sole community hospital that: |
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| 286 | 286 | | |
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| 287 | 287 | | (A) Has fewer than one hundred acute care licensed beds; |
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| 288 | 288 | | |
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| 289 | 289 | | (B) Has a level III adult trauma service designation from the department of health; and |
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| 290 | 290 | | |
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| 291 | 291 | | (C) Is owned and operated by the State. |
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| 292 | 292 | | |
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| 293 | 293 | | (e) The chief executive officer of a hospital shall submit a report to the hospital registered nurse staffing committee on a semiannual basis, before the staffing committee's semiannual review and adoption of an annual staffing plan. The report shall: |
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| 294 | 294 | | |
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| 295 | 295 | | (1) Identify elements of the staffing plan the chief executive officer requests changes to, if any; and |
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| 296 | 296 | | |
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| 297 | 297 | | (2) Provide a status of the implementation of the staffing plan, including nursing sensitive quality indicators collected by the hospital, patient surveys, and recruitment and retention efforts. |
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| 298 | 298 | | |
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| 299 | 299 | | (f) Beginning July 1, 2026, each hospital shall submit its hospital registered nurse staffing plan to the department. Thereafter, each hospital shall submit its staffing plan to the department on an annual basis and at any time that the staffing plan is updated. |
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| 300 | 300 | | |
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| 301 | 301 | | § -23 Implementation; complaints. (a) Beginning July 1, 2026, each hospital shall implement a hospital registered nurse staffing plan and assign personnel to each patient-care unit in accordance with the plan. |
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| 302 | 302 | | |
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| 303 | 303 | | (b) A registered nurse, collective bargaining representative if applicable, patient, or any other person may report to or file a complaint with the staffing committee any registered nurse assignment in a patient-care unit that deviates from the hospital registered nurse staffing plan in effect. |
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| 304 | 304 | | |
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| 305 | 305 | | (c) Shift-to-shift adjustments in registered nurse staffing levels required by the staffing plan may be made by the appropriate hospital personnel overseeing patient-care operations. If a person who is covered by a hospital registered nurse staffing plan on a patient-care unit objects to a shift‑to-shift adjustment, the person may file a complaint with the staffing committee. |
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| 306 | 306 | | |
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| 307 | 307 | | (d) The staffing committee shall develop a process to examine and respond to reports and complaints submitted pursuant to subsections (b) and (c), including the criteria and information needed to determine if a specific complaint is resolved or should be dismissed based on unsubstantiated information. The staffing committee shall review all reports and complaints received, regardless of the format of the report or complaint. |
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| 308 | 308 | | |
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| 309 | 309 | | § -24 Notice. Each hospital shall post, in a public area on each patient-care unit, the hospital registered nurse staffing plan and the staffing schedule for the shift of that unit, and the relevant clinical staffing for that shift. The staffing plan and current staffing levels shall also be made available to patients and visitors upon request. |
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| 310 | 310 | | |
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| 311 | 311 | | § -25 Retaliation prohibited. No hospital shall discipline, take any adverse employment action, or otherwise retaliate against or engage in any form of intimidation towards: |
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| 312 | 312 | | |
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| 313 | 313 | | (1) A registered nurse for performing any duties or responsibilities in connection with the staffing committee; |
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| 314 | 314 | | |
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| 315 | 315 | | (2) A registered nurse, patient, or other individual who notifies the staffing committee or the hospital administration of that person's concerns on the staffing of registered nurses; or |
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| 316 | 316 | | |
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| 317 | 317 | | (3) A registered nurse who refuses to work overtime. |
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| 318 | 318 | | |
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| 319 | 319 | | § -26 Critical access hospitals. Nothing in this part shall be construed to create unreasonable burdens on critical access hospitals under title 42 United States Code section 1395i4. Critical access hospitals may develop flexible approaches to accomplish the requirements of this part, including but not limited to having their hospital registered nurse staffing committees work by video conference, telephone, or email. |
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| 320 | 320 | | |
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| 321 | 321 | | § -27 Charter; filing requirements. The staffing committee shall file with the department a hospital registered nurse staffing committee charter that shall include: |
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| 322 | 322 | | |
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| 323 | 323 | | (1) Roles, responsibilities, and processes by which the staffing committee functions, including processes to ensure adequate quorum and attendance of staffing committee members, including giving them notice at least thirty days before a meeting; |
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| 324 | 324 | | |
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| 325 | 325 | | (2) A schedule for at least one meeting per month, with more frequent meetings as needed; |
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| 326 | 326 | | |
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| 327 | 327 | | (3) Processes by which all registered nurse staffing complaints will be reviewed, noting the date received as well as initial, contingent, and final disposition of complaints and corrective action plan where applicable; |
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| 328 | 328 | | |
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| 329 | 329 | | (4) Processes by which complaints will be resolved within ninety days of receipt, or longer with a majority approval of the staffing committee, and processes to ensure the complainant receives a letter stating the outcome of the complaint; |
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| 330 | 330 | | |
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| 331 | 331 | | (5) Processes for attendance by any employee, and a labor representative if requested by the employee, who is involved in a complaint; |
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| 332 | 332 | | |
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| 333 | 333 | | (6) Processes for the staffing committee to conduct quarterly reviews of registered nurse turnover rates, including new hire turnover rates during the first year of employment and hospital plans regarding workforce development; |
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| 334 | 334 | | |
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| 335 | 335 | | (7) Standards for the staffing committee's approval of meeting documentation, including meeting minutes, attendance, and actions taken; and |
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| 336 | 336 | | |
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| 337 | 337 | | (8) Policies for retention of meeting documentation for a minimum of three years; provided that the policy shall be consistent with each hospital's document retention policies. |
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| 338 | 338 | | |
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| 339 | 339 | | § -28 Department investigations. (a) The department shall investigate a complaint submitted under this section for alleged violations of this part following receipt of a complaint with documented evidence of a hospital's failure to: |
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| 340 | 340 | | |
|---|
| 341 | 341 | | (1) Establish a hospital registered nurse staffing committee; |
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| 342 | 342 | | |
|---|
| 343 | 343 | | (2) Conduct a semiannual review of its hospital registered nurse staffing plan; |
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| 344 | 344 | | |
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| 345 | 345 | | (3) Submit to the department its hospital registered nurse staffing plan on an annual basis and upon any updates; or |
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| 346 | 346 | | |
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| 347 | 347 | | (4) Assign registered nurses in a patient-care unit in compliance with section 11 or 23(a), or shift‑to-shift adjustments in registered nurse staffing levels in compliance with section 23(c). |
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| 348 | 348 | | |
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| 349 | 349 | | (b) If the department determines after an investigation conducted pursuant to subsection (a) that there has been a violation, the department shall require the hospital to submit a corrective plan of action within thirty days of the presentation of findings from the department to the hospital. |
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| 350 | 350 | | |
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| 351 | 351 | | (c) Hospitals shall not be found in violation of section -11 or 23(a) if the department determines, following an investigation, that: |
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| 352 | 352 | | |
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| 353 | 353 | | (1) There were unforeseeable emergent circumstances; or |
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| 354 | 354 | | |
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| 355 | 355 | | (2) The hospital, after consultation with its staffing committee, documents that the hospital has made reasonable efforts to obtain and retain staffing to meet the required registered nurse staffing assignments but has been unable to do so. |
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| 356 | 356 | | |
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| 357 | 357 | | (d) No later than thirty days after a hospital deviates from its hospital registered nurse staffing plan as adopted by its staffing committee, the hospital administration shall report to the staffing committee an assessment of the registered nurse staffing needs arising from the unforeseeable emergent circumstance and the hospital's plan to address those identified staffing needs. Upon receipt of the report, the staffing committee shall convene to develop a contingency staffing plan to address the needs arising from the unforeseeable emergent circumstance. The hospital's deviation from its staffing plan may not be in effect for more than thirty days without the approval of the staffing committee. |
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| 358 | 358 | | |
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| 359 | 359 | | (e) If a hospital fails to submit, or submits but fails to follow, a corrective plan of action in response to a violation or violations found by the department based on a complaint filed pursuant to subsection (a), the department may impose, for all violations asserted against a hospital at any time, a civil penalty of $5,000 per day; provided that the fine shall be $100 per day for hospitals: |
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| 360 | 360 | | |
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| 361 | 361 | | (1) Certified as a critical access hospital; |
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| 362 | 362 | | |
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| 363 | 363 | | (2) Having fewer than twentyfive acute care beds in operation; and |
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| 364 | 364 | | |
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| 365 | 365 | | (3) Certified by the federal Centers for Medicare and Medicaid services as a sole community hospital that: |
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| 366 | 366 | | |
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| 367 | 367 | | (A) Has less than one hundred fifty acute care licensed beds; |
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| 368 | 368 | | |
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| 369 | 369 | | (B) Has a level III adult trauma service designation from the department of health; and |
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| 370 | 370 | | |
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| 371 | 371 | | (C) Is owned and operated by the State. |
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| 372 | 372 | | |
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| 373 | 373 | | Civil penalties shall continue to apply until the hospital submits a corrective plan of action that has been approved by the department and follows the corrective plan of action for ninety days. Once the approved corrective action plan has been followed by the hospital for ninety days, the department may reduce the accumulated fine. The fine shall continue to accumulate until the ninety days have passed. |
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| 374 | 374 | | |
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| 375 | 375 | | (f) The department shall: |
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| 376 | 376 | | |
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| 377 | 377 | | (1) Maintain for public inspection records of any civil penalties and administrative actions imposed on hospitals under this section; and |
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| 378 | 378 | | |
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| 379 | 379 | | (2) Report violations of this chapter on its website. |
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| 380 | 380 | | |
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| 381 | 381 | | (g) Nothing in this chapter shall be construed to preclude the ability to otherwise submit a complaint to the department for failure to follow this chapter. |
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| 382 | 382 | | |
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| 383 | 383 | | § -29 Review of staffing plans by the department. (a) The department shall review each hospital registered nurse staffing plan submitted by a hospital to ensure submittal by the applicable deadline in the form prescribed by the department. |
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| 384 | 384 | | |
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| 385 | 385 | | (b) A hospital shall complete all portions of the hospital registered nurse staffing plan form prescribed by the department. The department may determine that a hospital has failed to timely submit its staffing plan if the staffing plan form is incomplete. |
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| 386 | 386 | | |
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| 387 | 387 | | (c) Failure to submit the hospital registered nurse staffing plan or hospital registered nurse staffing committee charter by the applicable deadline shall be a violation and shall be punishable by a civil penalty of $25,000 issued by the department. |
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| 388 | 388 | | |
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| 389 | 389 | | (d) The department shall post on its website: |
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| 390 | 390 | | |
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| 391 | 391 | | (1) Hospital registered nurse staffing plans received by the department; |
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| 392 | 392 | | |
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| 393 | 393 | | (2) Hospital registered nurse staffing committee charters received by the department; and |
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| 394 | 394 | | |
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| 395 | 395 | | (3) Violations of this section. |
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| 396 | 396 | | |
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| 397 | 397 | | part IV. Complaints |
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| 398 | 398 | | |
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| 399 | 399 | | § -31 Complaints. (a) If a complainant files a complaint with the department alleging a violation of this chapter, the department shall investigate the complaint; provided that nothing in this part shall prohibit the department from taking any other enforcement action authorized elsewhere in this chapter or pursuant to any other law. |
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| 400 | 400 | | |
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| 401 | 401 | | (b) The department shall not investigate any alleged violation of rights that occurred more than sixty days before the date on which the complainant filed the complaint. |
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| 402 | 402 | | |
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| 403 | 403 | | (c) Upon the investigation of a complaint, the department shall issue either a citation and notice of assessment or a closure letter, within ninety days after the date the department received the complaint, unless the complaint is otherwise resolved. The department may extend the ninety-day period by providing advance written notice to the complainant and the hospital setting forth good cause for the extension and the specific duration of the extension. |
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| 404 | 404 | | |
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| 405 | 405 | | (d) The department shall send a citation and notice of assessment or the closure letter to both the hospital and the complainant by service of process or another method that allows the delivery to the complainant's last known addresses to be tracked and confirmed. |
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| 406 | 406 | | |
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| 407 | 407 | | (e) If the department's investigation finds that the complainant's allegation cannot be substantiated, the department shall issue a closure letter to the complainant and the hospital detailing that finding. |
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| 408 | 408 | | |
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| 409 | 409 | | (f) Any hospital found by the department to be in violation of this chapter shall be subject to: |
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| 410 | 410 | | |
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| 411 | 411 | | (1) A fine not to exceed $1,000 for each of the first three violations; |
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| 412 | 412 | | |
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| 413 | 413 | | (2) $2,500 for the fourth violation; and |
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| 414 | 414 | | |
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| 415 | 415 | | (3) $5,000 for the fifth and each subsequent violation. (g) At any time, the department may waive or reduce a civil penalty assessed under this section if the director determines that the hospital has taken corrective action to resolve the violation. |
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| 416 | 416 | | |
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| 417 | 417 | | § -32 Appeals. (a) A person aggrieved by a citation and notice of assessment by the department under this chapter may appeal the citation and notice of assessment by filing a notice of appeal with the director within thirty days of the department's issuance of the citation and notice of assessment. A citation and notice of assessment not appealed within thirty days is final and binding, and shall not be subject to further appeal. |
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| 418 | 418 | | |
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| 419 | 419 | | (b) A notice of appeal filed with the director under this section shall stay the citation and notice of assessment pending final review of the appeal by the director. |
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| 420 | 420 | | |
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| 421 | 421 | | (c) Upon receipt of a notice of appeal, the director shall assign the matter to a hearings officer to hold a hearing and issue an initial order. The appeal process shall be conducted in accordance with chapter 91, and the standard of review by the hearings officer of an appealed citation and notice of assessment shall be de novo. Any party who seeks to challenge an initial order shall file a petition for administrative review with the director within thirty days after service of the initial order. The director shall conduct administrative review in accordance with chapter 91. |
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| 422 | 422 | | |
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| 423 | 423 | | (d) The director shall issue all final orders after appeal of the initial order. The final order of the director is subject to judicial review in accordance with chapter 91. |
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| 424 | 424 | | |
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| 425 | 425 | | (e) Orders that are not appealed within the time period specified in this section and chapter 91 are final and binding and not subject to further appeal. |
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| 426 | 426 | | |
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| 427 | 427 | | (f) A hospital that fails to allow adequate inspection of records in an investigation by the department under this chapter within a reasonable time period may not use those records in any appeal under this section to challenge the correctness of any determination by the department of the penalty assessed." |
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| 428 | 428 | | |
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| 429 | 429 | | SECTION 3. There is appropriated out of the general revenues of the State of Hawaii the sum of $ or so much thereof as may be necessary for fiscal year 2025-2026 and the same sum or so much thereof as may be necessary for fiscal year 2026-2027 to implement and enforce section 2 of this Act. |
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| 430 | 430 | | |
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| 431 | 431 | | The sums appropriated shall be expended by the department of labor and industrial relations for the purposes of this Act. |
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| 432 | 432 | | |
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| 433 | 433 | | SECTION 4. This Act does not affect rights and duties that matured, penalties that were incurred, and proceedings that were begun before its effective date. |
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| 434 | 434 | | |
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| 435 | 435 | | SECTION 5. This Act shall take effect upon its approval; provided that section 3 shall take effect on July 1, 2025. |
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| 436 | 436 | | |
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| 437 | 437 | | |
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| 438 | 438 | | |
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| 439 | 439 | | INTRODUCED BY: _____________________________ |
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| 440 | 440 | | |
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| 441 | 441 | | INTRODUCED BY: |
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| 442 | 442 | | |
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| 443 | 443 | | _____________________________ |
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| 444 | 444 | | |
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| 445 | 445 | | |
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| 446 | 446 | | |
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| 447 | 447 | | |
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| 448 | 448 | | |
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| 449 | 449 | | Report Title: DLIR; Health; Hospitals; Work Environment; Registered Nurses; Minimum Staffing Standard; Staffing Committee; Staffing Plan; Complaints; Penalties; Appeals; Appropriations Description: Establish certain minimum registered nurse-to-patient ratios for hospitals. Establishes a process to obtain a variance from the minimum registered nurse staffing standards. Requires hospitals to establish hospital registered nurse staffing committees by 9/1/2025 to develop and adopt registered nurse staffing plans. Requires the staffing committees to submit a charter to the Department of Labor and Industrial Relations. Beginning 7/1/2026, requires hospitals to submit their registered nurse staffing plan on an annual basis, and implement the staffing plan. Establishes a complaint and appeals process and penalties. Appropriates funds. The summary description of legislation appearing on this page is for informational purposes only and is not legislation or evidence of legislative intent. |
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| 450 | 450 | | |
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| 451 | 451 | | |
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| 452 | 452 | | |
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| 453 | 453 | | |
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| 454 | 454 | | |
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| 455 | 455 | | |
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| 456 | 456 | | |
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| 457 | 457 | | Report Title: |
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| 458 | 458 | | |
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| 459 | 459 | | DLIR; Health; Hospitals; Work Environment; Registered Nurses; Minimum Staffing Standard; Staffing Committee; Staffing Plan; Complaints; Penalties; Appeals; Appropriations |
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| 460 | 460 | | |
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| 461 | 461 | | |
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| 462 | 462 | | |
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| 463 | 463 | | Description: |
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| 464 | 464 | | |
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| 465 | 465 | | Establish certain minimum registered nurse-to-patient ratios for hospitals. Establishes a process to obtain a variance from the minimum registered nurse staffing standards. Requires hospitals to establish hospital registered nurse staffing committees by 9/1/2025 to develop and adopt registered nurse staffing plans. Requires the staffing committees to submit a charter to the Department of Labor and Industrial Relations. Beginning 7/1/2026, requires hospitals to submit their registered nurse staffing plan on an annual basis, and implement the staffing plan. Establishes a complaint and appeals process and penalties. Appropriates funds. |
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| 466 | 466 | | |
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| 467 | 467 | | |
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| 468 | 468 | | |
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| 469 | 469 | | |
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| 470 | 470 | | |
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| 471 | 471 | | |
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| 472 | 472 | | |
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| 473 | 473 | | The summary description of legislation appearing on this page is for informational purposes only and is not legislation or evidence of legislative intent. |
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