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131st MAINE LEGISLATURE
FIRST SPECIAL SESSION-2023
Legislative Document No. 1639S.P. 656 In Senate, April 12, 2023
An Act to Address Unsafe Staffing of Nurses and Improve Patient
Care
Reference to the Committee on Labor and Housing suggested and ordered printed.
DAREK M. GRANT
Secretary of the Senate
Presented by Senator BRENNER of Cumberland.
Cosponsored by Speaker TALBOT ROSS of Portland and
Senators: HICKMAN of Kennebec, President JACKSON of Aroostook, TIPPING of
Penobscot, Representatives: GEIGER of Rockland, GRAHAM of North Yarmouth,
MADIGAN of Waterville, ROEDER of Bangor, STOVER of Boothbay. Page 1 - 131LR0765(01)
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2 is enacted to read:
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6 This chapter may be known and cited as "the Maine Quality Care Act."
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8 All health care facilities are subject to the requirements of this chapter.
9 This chapter may not be construed to:
10 A. Change the scope of practice of registered nurses licensed under Title 32, chapter
11 31, subchapter 3; or
12 B. Provide an exemption from the minimum staffing requirements of direct-care
13 registered nurses if the patient condition or patient care unit name is different from the
14 term used in this chapter but the services provided are substantially similar.
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16 As used in this chapter, unless the context otherwise indicates, the following terms
17 have the following meanings.
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19 patient care services in a health care facility through regular, delegated tasks performed
20 under the coordination of a direct-care registered nurse for the delivery of safe, therapeutic
21 and effective patient care.
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23 integrate and act on the nurse's knowledge, skills, professional judgment and experience to
24 ensure safe, therapeutic and effective care to a specific patient population and for the
25 severity of illness in each patient care unit.
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27 declared by an authorized person within federal, state or local government relating to
28 circumstances that are unpredictable and unavoidable, affect the delivery of medical care
29 and require an immediate or exceptional level of emergency or other medical services at a
30 particular health care facility. "Declared state of emergency" does not include an
31 emergency relating to a labor dispute in the health care industry or consistent understaffing
32 in a health care facility.
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34 nurse licensed under Title 32, chapter 31, subchapter 3 who is primarily responsible for
35 providing direct, in-person, hands-on patient care in a health care facility by engaging in
36 the nursing process within the nurse's scope of practice while exercising professional
37 judgment in the best interests of the patient at all times. Page 2 - 131LR0765(01)
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2 405, a freestanding emergency department or an ambulatory surgical facility licensed under
3 chapter 405.
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5 which a patient receives care.
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7 care registered nurse's knowledge, expertise and experience and the nurse's assessment of
8 a patient, data, information and scientific evidence to understand the problems, issues or
9 concerns of a patient, to ensure safe, therapeutic and effective patient care and to make
10 independent decisions about a patient's care, including whether the assignment of ancillary
11 staff persons is appropriate.
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13 Except as provided in section 1795, a health care facility shall assign at least the
14 number of direct-care registered nurses at all times during every shift consistent with the
15 minimum requirements established in this section and at no time may a health care facility
16 assign fewer than 2 direct-care registered nurses in a patient care unit.
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18 no more than:
19 A. One patient when:
20 (1) The patient is receiving critical care or intensive care; or
21 (2) The nurse is assigned to a patient care unit, other than a unit providing
22 emergency services, that receives patients requiring critical care or intensive care,
23 including, but not limited to, a critical care unit, an intensive care unit or a patient
24 care unit with neonatal intensive care or pediatric intensive care patients;
25 B. One patient when:
26 (1) The patient is in an operating room; or
27 (2) The nurse is assigned to an operating room.
28 The health care facility shall assign a minimum of one scrub assistant for each patient
29 in an operating room in addition to the assigned direct-care registered nurse;
30 C. One patient when the patient is receiving conscious sedation;
31 D. One patient when:
32 (1) The patient is receiving postanesthesia care; or
33 (2) The nurse is assigned to a patient care unit that receives patients who require
34 postanesthesia care, including, but not limited to, a pediatric postanesthesia care
35 unit;
36 E. Three patients when:
37 (1) The patients are receiving step-down or intermediate care; or
38 (2) The nurse is assigned to a patient care unit that receives patients requiring step-
39 down or intermediate care, including, but not limited to, a step-down or
40 intermediate care unit; Page 3 - 131LR0765(01)
1 F. Three patients when:
2 (1) The patients are receiving emergency medical services and do not require
3 critical care or trauma services; or
4 (2) The nurse is assigned to a patient care unit that receives patients requiring
5 emergency medical services, including, but not limited to, an emergency
6 department or emergency room;
7 G. One patient when the patient is receiving emergency services and requires critical
8 care;
9 H. One patient when the patient is receiving emergency services and requires trauma
10 services;
11 I. Three patients when the patients are antepartum and not in active labor;
12 J. Two patients when the patients are antepartum and require continuous fetal
13 monitoring;
14 K. One patient when the nurse is assigned to initiate the patient for epidural anesthesia
15 or the nurse is assigned as the circulating nurse for a cesarean delivery;
16 L. One patient when the patient is in active labor;
17 M. One patient who is giving birth when the nurse has been assigned only to that patient
18 and one newborn patient when the nurse has been assigned only to that newborn
19 patient;
20 N. One newborn patient when the patient is unstable, as determined by the nurse;
21 O. One patient couplet of one parent and one newborn when the parent has given birth
22 within the previous 2 hours. In the case of multiple births, one direct-care registered
23 nurse must be assigned for each additional newborn when the direct-care registered
24 nurse has been assigned only to that newborn;
25 P. Two patient couplets of one parent and one newborn when the patients are
26 postpartum;
27 Q. Four patients when the patients are receiving postpartum or postoperative
28 gynecological care and when the nurse has been assigned only to patients receiving
29 postpartum or postoperative gynecological care;
30 R. Two newborn patients when:
31 (1) The patients are receiving intermediate care; or
32 (2) The nurse has been assigned to a patient care unit that receives newborn
33 patients requiring intermediate care, including, but not limited to, an intermediate
34 care nursery;
35 S. Three patients when:
36 (1) The patients have not attained 18 years of age; or
37 (2) The nurse is assigned to a patient care unit that receives patients who have not
38 attained 18 years of age, including, but not limited to, a pediatric unit;
39 T. Two patients who have not attained 18 years of age when: Page 4 - 131LR0765(01)
1 (1) The patients are receiving bone marrow transplant services; or
2 (2) The nurse is assigned to a patient care unit that receives bone marrow transplant
3 patients who have not attained 18 years of age;
4 U. One patient when:
5 (1) The patient is receiving coronary care services; or
6 (2) The nurse is assigned to a patient care unit that receives patients requiring
7 coronary care services;
8 V. One patient when:
9 (1) The patient requires burn care services; or
10 (2) The nurse is assigned to a patient care unit that receives patients requiring burn
11 care services;
12 W. One patient when:
13 (1) The patient is receiving acute respiratory care services; or
14 (2) The nurse is assigned to a patient care unit that receives patients requiring acute
15 respiratory care services;
16 X. Three patients when:
17 (1) The patients are receiving telemetry services; or
18 (2) The nurse is assigned to a patient care unit that receives patients requiring
19 telemetry services;
20 Y. Four patients when:
21 (1) The patients are receiving medical surgical care services; or
22 (2) The nurse is assigned to a patient care unit that receives patients requiring
23 medical surgical care services;
24 Z. Three patients when:
25 (1) The patients are receiving observational care services; or
26 (2) The nurse is assigned to a patient care unit that receives patients requiring
27 observational care services;
28 AA. Four patients when:
29 (1) The patients are receiving acute rehabilitation services; or
30 (2) The nurse is assigned to a patient care unit that receives patients requiring acute
31 rehabilitation services;
32 BB. Four patients when:
33 (1) The patients are receiving specialty care services; or
34 (2) The nurse is assigned to a patient care unit receiving patients requiring
35 specialty care services, including, but not limited to, a specialty care unit,
36 neurological care unit, gastrointestinal unit, orthopedic unit or any other unit that
37 is organized, operated and maintained to provide care for a specific medical
38 condition or a specific patient population; Page 5 - 131LR0765(01)
1 CC. Four patients when:
2 (1) The patients are receiving presurgical admissions services; or
3 (2) The nurse is assigned to a patient care unit that receives patients requiring
4 presurgical admissions services;
5 DD. Four patients when:
6 (1) The patients are receiving ambulatory surgical care services or procedures; or
7 (2) The nurse is assigned to a patient care unit that provides ambulatory surgical
8 care services or procedures;
9 EE. Four patients when:
10 (1) The patients are receiving psychiatric treatment or services; or
11 (2) The nurse is assigned to a patient care unit that receives patients requiring
12 psychiatric treatment or services; and
13 FF. Four patients in any other patient care unit or for any other patient condition.
14 A health care facility may assign a direct-care registered nurse to patients receiving triage
15 services as long as the nurse is performing only triage functions and is able to be
16 immediately available to patients requiring triage services arriving in a patient care unit
17 that receives patients requiring emergency medical services, including, but not limited to,
18 an emergency department or emergency room.
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20 a patient care unit in accordance with subsection 1 in order to meet the highest level of
21 intensity and type of care provided in the patient care unit. If more than one requirement
22 in subsection 1 applies to a patient, a health care facility shall assign a direct-care registered
23 nurse in accordance with the lowest numerical patient assignment applicable to the patient.
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25 patient requires the assignment of more than the number of direct-care registered nurses
26 required in accordance with this section, a health care facility shall assign additional direct-
27 care registered nurses to the patient consistent with the direct-care registered nurse's
28 professional judgment.
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30 The direct-care registered nurse staffing assignments required pursuant to section 1794
31 do not apply when there is a declared state of emergency. It is a defense to a complaint
32 alleging a violation of section 1794 filed against a health care facility under chapter 405 if
33 the facility demonstrates that it undertook prompt and diligent efforts to maintain the
34 staffing assignments required pursuant to section 1794, despite the declared state of
35 emergency.
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37 The following provisions apply to the calculation of the direct-care registered nurse
38 staffing assignments required pursuant to section 1794.
39 A patient must be assigned to a direct-care registered nurse. A patient
40 is considered to be assigned to a direct-care registered nurse if the nurse accepts
41 responsibility for the patient's care and meets the requirements under section 1797. Page 6 - 131LR0765(01)
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2 patients or number of direct-care registered nurses in a patient care unit during any one
3 shift or over any period of time.
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5 ancillary staff person or a nurse who does not provide direct, in-person, hands-on care to a
6 patient, including, but not limited to, a nurse administrator, nurse supervisor, nurse
7 manager, charge nurse or case manager. A registered nurse who is also a nurse
8 administrator, nurse supervisor, nurse manager, charge nurse, case manager or any other
9 health care facility administrator or supervisor may be included in the calculation of the
10 direct-care registered nurse staffing assignments required pursuant to section 1794 if the
11 registered nurse:
12 A. Has a current and active direct patient care assignment;
13 B. Provides direct patient care in compliance with the requirements of this chapter;
14 C. Has demonstrated current competency in providing care in the assigned patient care
15 unit and has received orientation to the unit sufficient to provide competent, safe,
16 therapeutic and effective care to patients in the unit;
17 D. Has the principal responsibility of providing direct patient care and has no
18 additional job duties during the time period during which the nurse has a patient
19 assignment; and
20 E. Is providing relief for a direct-care registered nurse during breaks, meals and other
21 routine or expected absences from the unit.
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23 person to perform tasks that involve professional judgment or the skill of a direct-care
24 registered nurse, including, but not limited to, patient assessment, evaluation and
25 implementation of a nursing care plan and administration of medications, even if the
26 provision of care is under the supervision of a direct-care registered nurse.
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28 nurse in the calculation unless the nurse has the principal responsibility of providing direct
29 patient care to the assigned patient and has no additional job duties other than direct patient
30 care, such as a nurse with triage, external communications or emergency transport duties.
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32 mandatory overtime requirement on a direct-care registered nurse.
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34 availability of ancillary staff persons in order to meet the direct-care registered nurse
35 staffing assignments required pursuant to section 1794.
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37 electronic monitoring, including, but not limited to, video monitoring or other remote
38 monitoring, to fulfill the staffing requirements.
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40 number of patients being treated in the facility resulting from circumstances such as
41 admissions, discharges and transfers of patients in order to maintain staffing ratios pursuant
42 to section 1794. Page 7 - 131LR0765(01)
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2 A health care facility shall, no less frequently than each shift, assign to a patient a
3 direct-care registered nurse responsible for the provision of care to the patient in accordance
4 with this section.
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6 not assign a direct-care registered nurse to a patient unless the nurse has demonstrated
7 current competency in providing care to patients in the patient care unit and has also
8 received orientation to the unit sufficient to provide care to patients.
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10 assign a direct-care registered nurse to relieve the originally assigned direct-care registered
11 nurse for breaks, meals or other routine, expected absences only if the relieving nurse has
12 demonstrated to the facility competency in providing care to patients in the patient care
13 unit and received orientation to the unit sufficient to provide care to patients.
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15 assignment under this section in its policies and procedures.
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18 may not use any form of electronic monitoring, including, but not limited to, video
19 monitoring or other remote monitoring to substitute for the direct observation by a direct-
20 care registered nurse or an ancillary staff person that is required for patient protection.
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22 policies or practices that:
23 A. Employ health information technology, algorithms used to achieve a medical or
24 nursing care objective, systems based on artificial intelligence or clinical practice
25 guidelines that limit or substitute for the direct care provided by an assigned direct-care
26 registered nurse in the performance of functions that are part of the nursing process,
27 including the full exercise of independent professional judgment, or that limit a direct-
28 care registered nurse from acting as a patient advocate in the exclusive interests of the
29 patient; or
30 B. Penalize a direct-care registered nurse for overriding technology or guidelines
31 prohibited in paragraph A if in the direct-care registered nurse's professional judgment
32 and in accordance with the direct-care registered nurse's scope of practice in
33 accordance with Title 32, chapter 31 it is in the best interest of the patient to do so.
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36 on the nurse's professional judgment and provide care in the exclusive interests of the
37 patient and to act as the patient's advocate.
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39 judgment in the performance of the nurse's duties within the nurse's scope of practice in
40 accordance with Title 32, chapter 31 in the exclusive interests of the patient. A direct-care
41 registered nurse's actions under this subsection may not, for any purpose, be considered,
42 relied upon or represented as a job function, authority, responsibility or activity undertaken Page 8 - 131LR0765(01)
43 for the purpose of serving the business, commercial, operational or other institutional
44 interests of the employer.
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4 therapeutic and effective nursing care to an assigned patient.
5 A. Before accepting a patient assignment, a direct-care registered nurse shall:
6 (1) Have the necessary knowledge, judgment, skills and ability to provide the
7 required care;
8 (2) Determine using the nurse's professional judgment whether the nurse is
9 competent to perform the nursing care needed by a patient who is in a particular
10 patient care unit or who has a particular diagnosis, condition, prognosis or other
11 determinative characteristic affecting nursing care; and
12 (3) Determine using the nurse's professional judgment whether acceptance of a
13 patient assignment would expose the patient or direct-care registered nurse to the
14 risk of harm.
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16 care registered nurse may object to or refuse to accept or participate in any activity, policy,
17 practice, assignment or task in a health care facility if the direct-care registered nurse:
18 A. Believes, based on the nurse's professional judgment, that the activity, policy,
19 practice, assignment or task would violate Title 32, chapter 31 or rules adopted
20 pursuant to that chapter or be outside the nurse's scope of practice;
21 B. Believes, based on the nurse's professional judgment, that the activity, policy,
22 practice, assignment or task would violate the staffing requirements under section 1794
23 or would violate any other provision of this chapter; or
24 C. Believes, based on the nurse's professional judgment, that the nurse is not prepared
25 by education, training or experience to fulfill the assignment without compromising
26 the safety of a patient or jeopardizing the license of the direct-care registered nurse.
27 A health care facility, an employee of a
28 health care facility who is primarily responsible for managing the facility or an employee
29 of the facility who is primarily responsible for providing patient care services may not:
30 A. Interfere with or prevent a direct-care registered nurse from exercising professional
31 judgment under this section;
32 B. Limit a direct-care registered nurse in performing duties that are a part of the nursing
33 process, including full exercise of professional judgment in assessment, planning,
34 implementation and evaluation of care;
35 C. Limit a direct-care registered nurse in acting as a patient advocate in the exclusive
36 interests of the patient; or
37 D. Discharge from duty, threaten or otherwise retaliate against a direct-care registered
38 nurse who reports an unsafe practice or violation of policy, federal or state law, federal
39 regulation or state rule.
40 A violation of subsection 5 is a
41 violation of Title 26, chapter 7, subchapter 5-B.
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2 A health care facility shall maintain and disclose records relating to actual staffing
3 assignments and any method used to meet the requirements of this chapter in accordance
4 with this section and rules adopted by the department.
5 Records maintained and disclosed under this section must
6 include:
7 A. The number of patients in each patient care unit during each shift;
8 B. The identity and duty hours of each direct-care registered nurse assigned to each
9 patient in each patient care unit during each shift;
10 C. The identity and duty hours of each ancillary staff person for each patient care unit
11 during each shift;
12 D. Certification that each direct-care registered nurse received rest and meal breaks and
13 the identity and duty hours of each direct-care registered nurse who provided relief
14 during the breaks; and
15 E. A copy of each notice required under subsection 4.
16 Records under this section must be
17 maintained for at least 3 years.
18 A health care facility shall submit all records
19 under this section to the department as a condition of licensure under chapter 405. The
20 chief nursing officer shall certify that records submitted to the department pursuant to this
21 subsection completely and accurately reflect staffing assignments in each patient care unit.
22 The certification must be executed under penalty of perjury and must contain an express
23 acknowledgment that any false statement constitutes fraud and is subject to criminal
24 prosecution or civil penalties.
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26 notice in a form specified by department rule that:
27 A. Explains the requirements of record maintenance under this section;
28 B. Includes actual direct-care registered nurse staffing assignments in each patient care
29 unit during each shift;
30 C. Includes the actual number of ancillary staff persons and the skill mix of the
31 ancillary staff persons in each patient care unit during each shift;
32 D. Identifies the variance between the required and actual staffing assignments in each
33 patient care unit during each shift; and
34 E. Is visible, conspicuous and accessible to health care facility staff, patients and the
35 public.
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37 available to the department, direct-care registered nurses, a nurse's collective bargaining
38 representative and the public.
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1 The department shall conduct periodic audits to ensure that a health care facility has
2 implemented the direct-care registered nurse staffing requirement pursuant to this chapter.
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4 In addition to the penalties available under section 1804 and licensure requirements
5 under section 1817, the department may impose a sanction under this section in conformity
6 with Title 5, chapter 375, subchapter 4.
7 The department may direct by written notice a health care facility to correct
8 any violations under this chapter and any rules adopted under this chapter in a manner and
9 within a time frame that the department determines appropriate to ensure compliance or
10 protect the public health. The health care facility shall correct any violations within the
11 time frame determined by the department.
12 The department may investigate complaints against a health care
13 facility in order to ensure compliance with this chapter and any rules adopted under this
14 chapter.
15 The department may impose the following administrative penalties on a
16 health care facility.
17 A. For violations of subsection 1 or sections 1794, 1796, 1797, 1798 and 1800 a rule
18 adopted to implement this section or those sections, the department may assess a fine
19 of not more than $10,000 per nursing shift in violation. Each day a health care facility
20 violates subsection 1 or section 1794, 1796, 1797, 1798 or 1800 is a separate offense.
21 B. For violations of section 1799, subsection 5 or a rule adopted to implement that
22 subsection, the department may assess a fine of not more than $25,000 per nursing
23 shift.
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25 This section governs violations under this chapter.
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27 to violations of sections 1794, 1796, 1797, 1798 and 1800 and section 1803, subsection 1.
28 A. A health care facility may not violate section 1794, 1796, 1797, 1798 or 1800 or
29 section 1803, subsection 1 or a rule adopted to implement those sections.
30 B. A health care facility that violates paragraph A commits a civil violation for which
31 a fine of not more than $10,000 per nursing shift in violation may be adjudged. Each
32 day a health care facility violates paragraph A is a separate offense.
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34 This subsection applies to violations of section 1799, subsection 5.
35 A. A health care facility, an employee of a health care facility who is primarily
36 responsible for managing the health care facility or an employee of a health care facility
37 who is primarily responsible for providing patient care services may not violate section
38 1799, subsection 5 or a rule adopted to implement that subsection.
39 B. A health care facility, an employee of a health care facility who is primarily
40 responsible for managing the health care facility or an employee of a health care facility
41 who is primarily responsible for providing patient care services who violates paragraph Page 11 - 131LR0765(01)
42 A commits a civil violation for which a fine of not more than $25,000 per nursing shift
43 in violation may be adjudged.
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4 The Attorney General may file a complaint with the District Court seeking civil
5 penalties or injunctive relief or both for violations of this chapter.
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7 A person may file a complaint with the department against a facility for violations of
8 this chapter. The department shall refer any complaint alleging a violation of section 1799,
9 subsection 5 to the Maine Human Rights Commission.
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11 The department may adopt rules to implement this chapter. The department shall rely
12 on and incorporate principles of the nursing profession in rules adopted pursuant to this
13 section. Rules adopted pursuant to this section are routine technical rules as defined in
14 Title 5, chapter 375, subchapter 2-A.
15 as repealed and replaced by PL 2007, c. 324, ยง4, is
16 amended to read:
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18 The department is authorized to issue licenses to operate hospitals, sanatoriums,
19 convalescent homes, rest homes, nursing homes, ambulatory surgical facilities and other
20 related institutions that, after inspection, are found to comply with this chapter, chapter
21 404-A and any rules adopted by the department. An initial license may be issued for up to
22 12 months. A license may be renewed for up to 24 months. The fee for this temporary or
23 conditional license is $15 and is payable at the time of issuance of the license regardless of
24 the term. When an institution, upon inspection by the department, is found not to meet all
25 requirements of this chapter or department rules, the department is authorized to issue
26 either:
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28 days, during which time corrections specified by the department must be made by the
29 institution for compliance with this chapter, chapter 404-A and departmental rules, if in the
30 judgment of the commissioner the best interests of the public will be so served; or
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32 met by the institution to the satisfaction of the department.
33 Failure of the institution to meet any of the department's conditions immediately voids
34 the temporary or conditional license by written notice by the department to the licensee or,
35 if the licensee cannot be reached for personal service, by notice left at the licensed premises.
36 A new application for a regular license may be considered by the department if, when and
37 after the conditions set forth by the department at the time of the issuance of this temporary
38 or conditional license have been met and satisfactory evidence of this fact has been
39 furnished to the department. The department may amend, modify or refuse to renew a
40 license in conformity with the Maine Administrative Procedure Act, or file a complaint
41 with the District Court requesting suspension or revocation of any license on any of the
42 following grounds: violation of this chapter or the rules issued adopted pursuant to this
43 chapter; violation of chapter 404-A or the rules adopted by the department pursuant to
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44 chapter 404-A; permitting, aiding or abetting the commission of any illegal act in that
45 institution; or conduct of practices detrimental to the welfare of a patient. Whenever, on
46 inspection by the department, conditions are found to exist that violate this chapter or
47 department rules issued adopted pursuant to this chapter or violate chapter 404-A or the
48 rules adopted by the department pursuant to chapter 404-A that, in the opinion of the
49 commissioner, immediately endanger the health or safety of patients in an institution or
50 create an emergency, the department by its duly authorized agents may, under the
51 emergency provisions of Title 4, section 184, subsection 6, request that the District Court
52 suspend or revoke the license. Rules adopted pursuant to this section are routine technical
53 rules as defined in Title 5, chapter 375, subchapter 2-A.
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12 This bill establishes the Maine Quality Care Act in order to ensure adequate direct-care
13 registered nurse staffing assignments in health care facilities, including hospitals,
14 freestanding emergency departments and ambulatory surgical facilities, to provide safe and
15 effective patient care. It establishes minimum direct-care registered nurse staffing
16 requirements based on patient care unit and patient needs, specifies the method to calculate
17 a health care facility's compliance with the staffing requirements, protects direct-care
18 registered nurses from retaliation and includes notice, record-keeping and enforcement
19 requirements.
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