(

a) For purposes of this section, the following

definitions shall apply: (1) “Direct care service hours” means the actual hours of work performed per patient day by a direct caregiver, as defined in paragraph (2). Until final regulations are promulgated to implement this

section as amended by the act that added this paragraph, the department shall recognize the hours performed by direct caregivers, to the same extent as those hours are recognized by the department pursuant to

Section 1276.5 on July 1, 2017. (2) “Direct caregiver” means a registered nurse, as referred to in

Section of the Business and Professions Code, a licensed vocational nurse, as referred to in

Section of the Business and Professions Code, a psychiatric technician, as referred to in

Section of the Business and Professions Code, and a certified nurse assistant, or a nursing assistant participating in an approved training program, as defined in

Section 1337, while performing nursing services as described in Sections 72309, 72311, and of Title of the California Code of Regulations, as those sections read on July 1, 2017. (3) “Skilled nursing facility” means a skilled nursing facility as defined in subdivision (

c) of

Section 1250. (

b) A person employed to provide services such as food preparation, housekeeping, laundry, or maintenance services shall not provide nursing care to residents and shall not be counted in determining ratios under this section. (c) (1) (

A) Notwithstanding any other law, the department shall develop regulations that become effective August 1, 2003, that establish staff-to-patient ratios for direct caregivers working in a skilled nursing facility. (

B) Effective July 1, 2018, skilled nursing facilities, except those skilled nursing facilities that are a distinct part of a general acute care facility or a state-owned hospital or developmental center, shall have a minimum number of direct care services hours of 3.5 per patient day, except as set forth in

Section 1276.9. (

C) Skilled nursing facilities shall have a minimum of 2.4 hours per patient day for certified nurse assistants in order to meet the requirements in subparagraph (B). (

D) The department shall repeal and amend existing regulations and adopt emergency regulations to implement the amendments made by the act that added this subparagraph. The department shall consult stakeholders prior to promulgation of regulations and shall provide a 90-day notice to stakeholders prior to adopting regulations. The adoption of these regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health and safety, or general welfare.

(2) The department, in developing staff-to-patient ratios for direct caregivers and licensed nurses required by this section, shall convert the existing requirement under

Section 1276.5 of this code and

Section 14110.7 of the Welfare and Institutions Code for direct care service hours per patient day of care and shall verify that no less care is given than is required pursuant to

Section 1276.5 of this code and

Section 14110.7 of the Welfare and Institutions Code. Further, the department shall develop the ratios in a manner that minimizes additional state costs, maximizes resident quality of care, and takes into account the length of the shift worked. In developing the regulations, the department shall develop a procedure for facilities to apply for a waiver that addresses individual patient needs except that in no instance shall the minimum staff-to-patient ratios be less than the 3.5 direct care service hours per patient day required pursuant to subparagraph (

B) of paragraph (1). (

d) The direct care service hour requirements to be developed pursuant to this

section shall be minimum standards only. Skilled nursing facilities shall employ and

schedule additional staff as needed to ensure quality resident care based on the needs of individual residents and to ensure compliance with all relevant state and federal staffing requirements. (

e) No later than January 1, 2006, and every five years thereafter, the department shall consult with consumers, consumer advocates, recognized collective bargaining agents, and providers to determine the sufficiency of the staffing standards provided in this

section and may adopt regulations to increase the minimum staffing ratios to adequate levels. (

f) In a manner pursuant to federal requirements, every skilled nursing facility shall post information about staffing levels that includes the current number of licensed and unlicensed nursing staff directly responsible for resident care in the facility. This posting shall include staffing requirements developed pursuant to this section. (g)

(1) Notwithstanding any other law, the department shall inspect for compliance with this

section during state and federal periodic inspections, including, but not limited to, those inspections required under

Section 1422. This inspection requirement shall not limit the department’s authority in other circumstances to cite for violations of this

section or to inspect for compliance with this section.

(2) A violation of the regulations developed pursuant to this

section may constitute a class “B,” “A,” or “AA” violation pursuant to the standards set forth in

Section 1424. The department shall set a timeline for phase-in of penalties pursuant to this

section through all-facility letters or other similar instructions. (

h) The requirements of this

section are in addition to any requirement set forth in

Section 1276.5 of this code and

Section 14110.7 of the Welfare and Institutions Code. (

i) Implementation of the staffing standard developed pursuant to requirements set forth in this

section shall be contingent on an appropriation in the annual Budget Act and continued federal approval of the Skilled Nursing Facility Quality Assurance Fee pursuant to

Article 7.6 (commencing with

Section 1324.20). (

j) In implementing this section, the department may contract as necessary, on a bid or nonbid basis, for professional consulting services from nationally recognized higher education and research institutions, or other qualified individuals and entities not associated with a skilled nursing facility, with demonstrated expertise in long-term care. This subdivision establishes an accelerated process for issuing contracts pursuant to this

section and contracts entered into pursuant to this

section shall be exempt from the requirements of

Chapter 1 (commencing with

Section 10100) and

Chapter 2 (commencing with

Section 10290) of Part of Division of the Public Contract Code. (

k) This

section shall not apply to facilities defined in

Section 1276.9. (

l) The department shall adopt emergency regulations or all-facility letters, or other similar instructions, to create a waiver of the direct care service hour requirements established in this

section for skilled nursing facilities by July 1, 2018, to address a shortage of available and appropriate health care professionals and direct caregivers. Waivers granted pursuant to these provisions shall be reviewed annually and either renewed or revoked. The adoption of these regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health and safety, or general welfare. (

m) The department shall evaluate the impact of the changes made to this

section by the act that added this subdivision regarding patient quality of care and shall work with other state departments, as necessary, to evaluate the workforce available to meet these requirements, including an evaluation of the effectiveness of the minimum requirements of 2.4 hours per patient day for certified nursing assistants specified in subparagraph (

C) of paragraph (1) of subdivision (c). The department may contract with a vendor for purposes of conducting this evaluation.