Florida Senate - 2020 SB 204 By Senator Braynon 35-00171-20 2020204__ Page 1 of 35 CODING: Words stricken are deletions; words underlined are additions. A bill to be entitled 1

An act relating to delivery of nursing services; 2 creating the “Florida Hospital Patient Protection 3 Act”; creating s. 395.1014, F.S.; providing 4 legislative findings; defining terms; requiring that 5 each health care facility implement a staffing plan 6 that provides minimum direct care registered nurse 7 staffing levels; requiring a direct care registered 8 nurse to demonstrate competence and to receive 9 specified orientation before being assigned to a 10 hospital or clinical unit; prohibiting a health care 11 facility from imposing mandatory overtime and from 12 engaging in other specified actions; providing 13 requirements for the staffing plan; specifying the 14 required ratios of direct care registered nurses to 15 patients for each type of care provided; prohibiting a 16 health care facility from using an acuity-adjustable 17 unit to care for a patient; prohibiting a health care 18 facility from using video cameras or monitors as 19 substitutes for the required level of care; providing 20 an exception during a declared state of emergency; 21 requiring that the chief nursing officer of a health 22 care facility, or his or her designee, develop a 23 staffing plan that meets the required direct care 24 registered nurse staffing levels; requiring that a 25 health care facility annually evaluate its actual 26 direct care registered nurse staffing levels and 27 update the staffing plan and acuity-based patient 28 classification system; requiring that certain 29

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 2 of 35 CODING: Words stricken are deletions; words underlined are additions. documentation be submitted to the Agency for Health 30 Care Administration and be made available for public 31 inspection; requiring that the agency approve uniform 32 standards for use by health care facilities in 33 establishing direct care registered nurse staffing 34 requirements by a specified date; requiring a 35 committee to develop and evaluate a staffing plan for 36 each health care facility within a specified 37 timeframe; providing requirements for committee 38 membership; requiring health care facilities to 39 annually report certain information to the agency and 40 to post a notice containing such information in each 41 unit of the facility; providing recordkeeping 42 requirements; prohibiting a health care facility from 43 assigning unlicensed personnel to perform functions or 44 tasks that should be performed by a licensed or 45 registered nurse; specifying those actions that 46 constitute professional practice by a direct care 47 registered nurse; providing requirements for patient 48 assessment and requiring that such assessment be 49 performed only by a direct care registered nurse; 50 authorizing a direct care registered nurse to assign 51 certain specified activities to other licensed or 52 unlicensed nursing staff under certain circumstances; 53 prohibiting a health care facility from deploying 54 technology that limits certain care provided by a 55 direct care registered nurse; providing applicability; 56 providing that it is a duty and right of a direct care 57 registered nurse to act as the patient’s advocate and 58

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 3 of 35 CODING: Words stricken are deletions; words underlined are additions. providing requirements relating thereto; prohibiting a 59 direct care registered nurse from accepting an 60 assignment under specified circumstances; authorizing 61 a direct care registered nurse to refuse to accept an 62 assignment or to perform a task under certain 63 circumstances; requiring a direct care registered 64 nurse to initiate action or to change a decision or an 65 activity relating to a patient’s health care under 66 certain circumstances; prohibiting a health care 67 facility from discharging, or from discriminating, 68 retaliating, or filing a complaint or report against, 69 a direct care registered nurse based on such refusal; 70 authorizing a direct care registered nurse to bring a 71 cause of action under certain circumstances; 72 authorizing certain entities to file a complaint with 73 the agency against a health care facility under 74 certain circumstances; requiring the agency to 75 investigate such complaints and issue certain orders 76 if certain findings are made; prohibiting a health 77 care facility from discriminating or retaliating 78 against those entities making such complaints; 79 prohibiting a health care facility from taking certain 80 actions in certain situations; prohibiting a health 81 care facility from interfering with the right of 82 direct care registered nurses to organize, bargain 83 collectively, and engage in concerted activity under a 84 federal act; requiring a health care facility to post 85 a certain notice in each hospital or clinical unit; 86 requiring that the agency establish a toll-free 87

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 4 of 35 CODING: Words stricken are deletions; words underlined are additions. telephone hotline to provide certain information and 88 to receive reports of certain violations; requiring 89 that certain information be provided to each patient 90 who is admitted to a health care facility; authorizing 91 the agency to impose fines for violations; requiring 92 that the agency post on its website information 93 regarding health care facilities on which civil 94 penalties have been imposed; providing an effective 95 date. 96 97 Be It Enacted by the Legislature of the State of Florida: 98 99

Section 1.

Short title.—This act may be cited as the 100 “Florida Hospital Patient Protection Act.” 101

Section

Section 395.1014, Florida Statutes, is created 102 to read: 103 395.1014 Health care facility patient care standards.— 104

(1) LEGISLATIVE FINDINGS.—The Legislature finds that: 105 (

a) The state has a substantial interest in ensuring that, 106 in the delivery of health care services to patients, health care 107 facilities retain sufficient nursing staff to promote optimal 108 health care outcomes. 109 (

b) Health care services are becoming more complex, and it 110 is increasingly difficult for patients to access integrated 111 services. Competent, safe, therapeutic, and effective patient 112 care is jeopardized because of staffing changes implemented in 113 response to market-driven managed care. To ensure effective 114 protection of patients in acute care settings, it is essential 115 that qualified direct care registered nurses be accessible and 116

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 5 of 35 CODING: Words stricken are deletions; words underlined are additions. available to meet the individual needs of the patient at all 117 times. Also, to ensure the health and welfare of residents and 118 to ensure that hospital nursing care is provided in the 119 exclusive interests of patients, mandatory practice standards 120 and professional practice protections for professional direct 121 care registered nursing staff must be established.

Direct care 122 registered nurses have a duty to care for assigned patients and 123 a necessary duty of individual and collective patient advocacy 124 to satisfy professional obligations. 125 (

c) The basic principles of staffing in hospital settings 126 should be based on the care needs of the individual patient, the 127 severity of the patient’s condition, the services needed, and 128 the complexity surrounding those services. Current unsafe 129 practices by hospital direct care registered nursing staff have 130 resulted in adverse patient outcomes.

Mandating the adoption of 131 uniform, minimum, numerical, and specific direct care registered 132 nurse-to-patient staffing ratios by licensed hospital facilities 133 is necessary for competent, safe, therapeutic, and effective 134 professional nursing care and for the retention and recruitment 135 of qualified direct care registered nurses. 136 (

d) Direct care registered nurses must be able to advocate 137 for their patients without fear of retaliation from their 138 employers. Whistle-blower protections that encourage direct care 139 registered nurses and patients to notify governmental and 140 private accreditation entities of suspected unsafe patient 141 conditions, including protection against retaliation for 142 refusing unsafe patient care assignments, will greatly enhance 143 the health, safety, and welfare of patients. 144 (

e) Direct care registered nurses have an irrevocable duty 145

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 6 of 35 CODING: Words stricken are deletions; words underlined are additions. and right to advocate on behalf of their patients’ interests, 146 and this duty and right may not be encumbered by cost-saving 147 practices. 148

(2) DEFINITIONS.—As used in this section, the term: 149 (a) “Acuity-based patient classification system” or 150 “patient classification system” means an established measurement 151 tool that: 152 1.

Predicts registered nursing care requirements for 153 individual patients based on the severity of a patient’s 154 illness; the need for specialized equipment and technology; the 155 intensity of required nursing interventions; the complexity of 156 clinical nursing judgment required to design, implement, and 157 evaluate the patient nursing care plan consistent with 158 professional standards; the ability for self-care, including 159 motor, sensory, and cognitive deficits; and the need for 160 advocacy intervention; 161 2.

Details the amount of nursing care needed and the 162 additional number of direct care registered nurses and other 163 licensed and unlicensed nursing staff that the hospital must 164 assign, based on the independent professional judgment of a 165 direct care registered nurse, to meet the needs of individual 166 patients at all times; and 167 3.

Can be readily understood and used by direct care 168 nursing staff. 169 (b) “Ancillary support staff” means the personnel assigned 170 to assist in providing nursing services for the delivery of 171 safe, therapeutic, and effective patient care, including unit or 172 ward clerks and secretaries; clinical technicians; respiratory 173 therapists; and radiology, laboratory, housekeeping, and dietary 174

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 7 of 35 CODING: Words stricken are deletions; words underlined are additions. personnel. 175 (c) “Clinical supervision” means the assignment and 176 direction of a patient care task required in the implementation 177 of nursing care for a patient to other licensed nursing staff or 178 to unlicensed staff by a direct care registered nurse in the 179 exclusive interests of the patient. 180 (d) “Competence” means the ability of a direct care 181 registered nurse to act upon and integrate the knowledge, 182 skills, abilities, and independent professional judgment that 183 underpin safe, therapeutic, and effective patient care. 184 (e) “Declared state of emergency” means an officially 185 designated state of emergency that has been declared by a 186 federal, state, or local government official who has the 187 authority to declare the state of emergency.

The term does not 188 include a state of emergency that results from a labor dispute 189 in the health care industry. 190 (f) “Direct care registered nurse” means a registered nurse 191 or licensed practical nurse, as defined in s. 464.003: 192 1. Who is licensed by the Board of Nursing to engage in the 193 practice of professional nursing or the practice of practical 194 nursing, as defined in s. 464.003; 195 2. Whose competence has been documented; and 196 3.

Who has accepted a direct, hands-on patient care 197 assignment to implement medical and nursing regimens and provide 198 related clinical supervision of patient care while exercising 199 independent professional judgment at all times in the exclusive 200 interests of the patient. 201 (g) “Health care facility unit” means an acute care 202 hospital; an emergency care, ambulatory, or outpatient surgery 203

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 8 of 35 CODING: Words stricken are deletions; words underlined are additions. facility licensed under this chapter; or a psychiatric facility 204 licensed under

chapter 394. 205 (h) “Hospital unit” or “clinical unit” means an acuity-206 adjustable unit, critical care unit or intensive care unit, 207 labor and delivery unit, antepartum and postpartum unit, newborn 208 nursery, postanesthesia unit, emergency department, operating 209 room, pediatric unit, rehabilitation unit, skilled nursing unit, 210 specialty care unit, step-down unit or intermediate intensive 211 care unit, surgical unit, telemetry unit, or psychiatric unit. 212 1. “Acuity-adjustable unit” means a unit that adjusts a 213 room’s technology, monitoring systems, and intensity of nursing 214 care based on the severity of the patient’s medical condition. 215 2. “Critical care unit” or “intensive care unit” means a 216 nursing unit established to safeguard and protect a patient 217 whose severity of medical condition requires continuous 218 monitoring and complex intervention by a direct care registered 219 nurse and whose restorative measures and level of nursing 220 intensity require intensive care through direct observation; 221 complex monitoring; intensive intricate assessment; evaluation; 222 specialized rapid intervention; and education or teaching of the 223 patient, the patient’s family, or other representatives by a 224 competent and experienced direct care registered nurse.

The term 225 includes a burn unit, coronary care unit, or acute respiratory 226 unit. 227 3. “Rehabilitation unit” means a functional clinical unit 228 established to provide rehabilitation services that restore an 229 ill or injured patient to the highest level of self-sufficiency 230 or gainful employment of which he or she is capable in the 231 shortest possible time; compatible with his or her physical, 232

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 9 of 35 CODING: Words stricken are deletions; words underlined are additions. intellectual, and emotional or psychological capabilities; and 233 in accordance with planned goals and objectives. 234 4. “Skilled nursing unit” means a functional clinical unit 235 established to provide skilled nursing care and supportive care 236 to patients whose primary need is for skilled nursing care on a 237 long-term basis and who are admitted after at least a 48-hour 238 period of continuous inpatient care.

The term includes, but is 239 not limited to, a unit established to provide medical, nursing, 240 dietary, and pharmaceutical services and activity programs. 241 5. “Specialty care unit” means a unit established to 242 safeguard and protect a patient whose severity of illness, 243 including all co-occurring morbidities, restorative measures, 244 and level of nursing intensity, requires continuous care through 245 direct observation and monitoring; multiple assessments; 246 specialized interventions; evaluations; and education or 247 teaching of the patient, the patient’s family, or other 248 representatives by a competent and experienced direct care 249 registered nurse.

The term includes, but is not limited to, a 250 unit established to provide the intensity of care required for a 251 specific medical condition or a specific patient population or 252 to provide more comprehensive care for a specific condition or 253 disease than the care required in a surgical unit. 254 6. “Step-down unit” or “intermediate intensive care unit” 255 means a unit established to safeguard and protect a patient 256 whose severity of illness, including all co-occurring 257 morbidities, restorative measures, and level of nursing 258 intensity, requires intermediate intensive care through direct 259 observation and monitoring; multiple assessments; specialized 260 interventions; evaluations; and education or teaching of the 261

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 10 of 35 CODING: Words stricken are deletions; words underlined are additions. patient, the patient’s family, or other representatives by a 262 competent and experienced direct care registered nurse. The term 263 includes a unit established to provide care to patients who have 264 moderate or potentially severe physiological instability 265 requiring technical support, but not necessarily artificial life 266 support.

As used in this subparagraph, the term: 267 a. “Artificial life support” means a system that uses 268 medical technology to aid, support, or replace a vital function 269 of the body which has been seriously damaged. 270 b. “Technical support” means the use of specialized 271 equipment by a direct care registered nurse in providing for 272 invasive monitoring, telemetry, and mechanical ventilation for 273 the immediate amelioration or remediation of severe pathology 274 for a patient requiring less care than intensive care, but more 275 care than the care provided in a surgical unit. 276 7. “Surgical unit” means a unit established to safeguard 277 and protect a patient whose severity of illness, including all 278 co-occurring morbidities, restorative measures, and level of 279 nursing intensity, requires continuous care through direct 280 observation and monitoring; multiple assessments; specialized 281 interventions; evaluations; and education or teaching of the 282 patient, the patient’s family, or other representatives by a 283 competent and experienced direct care registered nurse.

The term 284 includes a unit established to provide care to patients who 285 require less than intensive care or step-down care; patients who 286 receive 24-hour inpatient general medical care or postsurgical 287 care, or both; and mixed populations of patients of diverse 288 diagnoses and diverse ages, excluding pediatric patients. 289 8. “Telemetry unit” means a unit established to safeguard 290

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 11 of 35 CODING: Words stricken are deletions; words underlined are additions. and protect a patient whose severity of illness, including all 291 co-occurring morbidities, restorative measures, and level of 292 nursing intensity, requires intermediate intensive care through 293 direct observation and monitoring; multiple assessments; 294 specialized interventions; evaluations; and education or 295 teaching of the patient, the patient’s family, or other 296 representatives by a competent and experienced direct care 297 registered nurse.

The term includes a unit in which specialized 298 equipment is used to provide for the electronic monitoring, 299 recording, retrieval, and display of cardiac electrical signals. 300 (i) “Long-term acute care hospital” means a hospital or 301 health care facility that specializes in providing long-term 302 acute care to medically complex patients. The term includes a 303 freestanding and hospital-within-hospital model of a long-term 304 acute care facility. 305 (j) “Overtime” means the hours worked in excess of: 306 1. An agreed-upon, predetermined, regularly scheduled 307 shift; 308 2.

Twelve hours in a 24-hour period; or 309 3.

Eighty hours in a 14-day period. 310 (k) “Patient assessment” means the use of critical thinking 311 by a direct care registered nurse, and the intellectually 312 disciplined process of actively and skillfully interpreting, 313 applying, analyzing, synthesizing, or evaluating data obtained 314 through direct observation and communication with others. 315 (l) “Professional judgment” means the intellectual, 316 educated, informed, and experienced process that a direct care 317 registered nurse exercises in forming an opinion and reaching a 318 clinical decision that is in the exclusive interests of the 319

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 12 of 35 CODING: Words stricken are deletions; words underlined are additions. patient and is based upon the analysis of data, information, and 320 scientific evidence. 321 (m) “Skill mix” means the differences in licensing, 322 specialty, and experience among direct care registered nurses. 323

(3) MINIMUM DIRECT CARE REGISTERED NURSE STAFFING LEVEL 324 REQUIREMENTS.— 325 (

a) A health care facility shall implement a staffing plan 326 that provides for a minimum direct care registered nurse 327 staffing level in accordance with the general requirements set 328 forth in this subsection and the direct care registered nurse 329 staffing levels in a clinical unit as specified in paragraph 330 (b). Staffing levels for patient care tasks that do not require 331 a direct care registered nurse are not included within these 332 ratios and shall be determined pursuant to an acuity-based 333 patient classification system defined by agency rule. 334 1.

A health care facility may not assign a direct care 335 registered nurse to a clinical unit unless the health care 336 facility and the direct care registered nurse determine that 337 such nurse has demonstrated competence in providing care in the 338 clinical unit and has also received orientation in the clinical 339 unit’s area of specialty which is sufficient to provide 340 competent, safe, therapeutic, and effective care to a patient in 341 that unit. The policies and procedures of the health care 342 facility must contain the criteria for making this 343 determination. 344 2.

The direct care registered nurse staffing levels 345 represent the maximum number of patients that may be assigned to 346 one direct care registered nurse at any one time. 347 3. A health care facility: 348

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 13 of 35 CODING: Words stricken are deletions; words underlined are additions. a. May not average the total number of patients and the 349 total number of direct care registered nurses assigned to 350 patients in a hospital unit or clinical unit during any period 351 for purposes of meeting the requirements under this subsection. 352 b. May not impose mandatory overtime in order to meet the 353 minimum direct care registered nurse staffing levels in the 354 hospital unit or clinical unit which are required under this 355 subsection. 356 c.

Shall ensure that only a direct care registered nurse 357 may relieve another direct care registered nurse during breaks, 358 meals, and routine absences from a hospital unit or clinical 359 unit. 360 d. May not lay off licensed practical nurses, licensed 361 psychiatric technicians, certified nursing assistants, or other 362 ancillary support staff to meet the direct care registered nurse 363 staffing levels required in this subsection for a hospital unit 364 or clinical unit. 365 4.

Only a direct care registered nurse may be assigned to 366 an intensive care newborn nursery service unit, which 367 specifically requires a direct care registered nurse staffing 368 level of one such nurse to two or fewer infants at all times. 369 5. In the emergency department, only a direct care 370 registered nurse may be assigned to a triage patient or a 371 critical care patient. 372 a. The direct care registered nurse staffing level for 373 triage patients or critical care patients in the emergency 374 department must be one such nurse to two or fewer patients at 375 all times. 376 b.

At least two direct care registered nurses must be 377

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 14 of 35 CODING: Words stricken are deletions; words underlined are additions. physically present in the emergency department when a patient is 378 present. 379 c. Triage, radio, specialty, or flight registered nurses do 380 not count in the calculation of direct care registered nurse 381 staffing levels. Triage registered nurses may not be assigned 382 the responsibility of the base radio. 383 6. Only a direct care registered nurse may be assigned to a 384 labor and delivery unit. 385 a.

The direct care registered nurse staffing level must be 386 one such nurse to one active labor patient, or one patient 387 having medical or obstetrical complications, during the 388 initiation of epidural anesthesia and during circulation for a 389 caesarean

section delivery. 390 b. The direct care registered nurse staffing level for 391 antepartum patients who are not in active labor must be one such 392 nurse to three or fewer patients at all times. 393 c. In the event of a caesarean delivery, the direct care 394 registered nurse staffing level must be one such nurse to four 395 or fewer mother-plus-infant couplets. 396 d. In the event of multiple births, the direct care 397 registered nurse staffing level must be one such nurse to six or 398 fewer mother-plus-infant couplets. 399 e.

The direct care registered nurse staffing level for 400 postpartum areas in which the direct care registered nurse’s 401 assignment consists of only mothers must be one such nurse to 402 four or fewer patients at all times. 403 f. The direct care registered nurse staffing level for 404 postpartum patients or postsurgical gynecological patients must 405 be one such nurse to four or fewer patients at all times. 406

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 15 of 35 CODING: Words stricken are deletions; words underlined are additions. g. The direct care registered nurse staffing level for the 407 well-baby nursery unit must be one such nurse to five or fewer 408 patients at all times. 409 h. The direct care registered nurse staffing level for 410 unstable newborns and newborns in the resuscitation period as 411 assessed by a direct care registered nurse must be at least one 412 such nurse to one patient at all times. 413 i.

The direct care registered nurse staffing level for 414 newborns must be one such nurse to four or fewer patients at all 415 times. 416 7. The direct care registered nurse staffing level for 417 patients receiving conscious sedation must be at least one such 418 nurse to one patient at all times. 419 (

b) A health care facility’s staffing plan must provide 420 that, at all times during each shift within a unit of the 421 facility, a direct care registered nurse is assigned to not more 422 than: 423 1. One patient in a trauma emergency unit; 424 2. One patient in an operating room unit. The operating 425 room must have at least one direct care registered nurse 426 assigned to the duties of the circulating registered nurse and a 427 minimum of one additional person as a scrub assistant for each 428 patient-occupied operating room; 429 3.

Two patients in a critical care unit, including neonatal 430 intensive care units; emergency critical care and intensive care 431 units; labor and delivery units; coronary care units; acute 432 respiratory care units; postanesthesia units, regardless of the 433 type of anesthesia administered; and postpartum units, so that 434 the direct care registered nurse staffing level is one such 435

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 16 of 35 CODING: Words stricken are deletions; words underlined are additions. nurse to two or fewer patients at all times; 436 4. Three patients in an emergency room unit; step-down unit 437 or intermediate intensive care unit; pediatric unit; telemetry 438 unit; or combined labor and postpartum unit so that the direct 439 care registered nurse staffing level is one such nurse to three 440 or fewer patients at all times; 441 5.

Four patients in a surgical unit, antepartum unit, 442 intermediate care nursery unit, psychiatric unit, or presurgical 443 or other specialty care unit so that the direct care registered 444 nurse staffing level is one such nurse to four or fewer patients 445 at all times; 446 6. Five patients in a rehabilitation unit or skilled 447 nursing unit so that the direct care registered nurse staffing 448 level is one such nurse to five or fewer patients at all times; 449 7.

Six patients in a well-baby nursery unit so that the 450 direct care registered nurse staffing level is one such nurse to 451 six or fewer patients at all times; or 452 8. Three mother-plus-infant couplets in a postpartum unit 453 so that the direct care registered nurse staffing level is one 454 such nurse to three or fewer mother-plus-infant couplets at all 455 times. 456 (c)1.

Identifying a hospital unit or clinical unit by a 457 name or term other than those defined in subsection (2) does not 458 affect the requirement of direct care registered nurse staffing 459 levels identified for the level of intensity or type of care 460 described in paragraphs (

a) and (b). 461 2. Patients shall be cared for only in hospital units or 462 clinical units in which the level of intensity, type of care, 463 and direct care registered nurse staffing levels meet the 464

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 17 of 35 CODING: Words stricken are deletions; words underlined are additions. individual requirements and needs of each patient. A health care 465 facility may not use an acuity-adjustable unit to care for a 466 patient. 467 3. A health care facility may not use a video camera or 468 monitor or any form of electronic visualization of a patient to 469 substitute for the direct observation required for patient 470 assessment by the direct care registered nurse and for patient 471 protection provided by an attendant. 472 (

d) The requirements established under this subsection do 473 not apply during a declared state of emergency, as defined in 474 subsection (2), if a health care facility is requested or 475 expected to provide an exceptional level of emergency or other 476 medical services. 477 (

e) The chief nursing officer or his or her designee shall 478 develop a staffing plan for each hospital unit or clinical unit. 479 1. The staffing plan must be in writing and, based on 480 individual patient care needs determined by the acuity-based 481 patient classification system, must specify individual patient 482 care requirements and the staffing levels for direct care 483 registered nurses and other licensed and unlicensed personnel. 484 The direct care registered nurse staffing level on any shift may 485 not fall below the requirements in paragraphs (

a) and (

b) at any 486 time. 487 2. In addition to the requirements of direct care 488 registered nurse staffing levels in paragraphs (

a) and (b), each 489 health care facility shall assign additional nursing staff, 490 including, but not limited to, licensed practical nurses, 491 licensed psychiatric technicians, and certified nursing 492 assistants, through the implementation of a valid acuity-based 493

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 18 of 35 CODING: Words stricken are deletions; words underlined are additions. patient classification system for determining nursing care needs 494 of individual patients which reflects the assessment of patient 495 nursing care requirements made by the assigned direct care 496 registered nurse and which provides for shift-by-shift staffing 497 based on those requirements. The direct care registered nurse 498 staffing levels specified in paragraphs (

a) and (

b) constitute 499 the minimum number of direct care registered nurses who shall be 500 assigned to provide direct patient care. 501 3. In developing the staffing plan, a health care facility 502 shall provide for direct care registered nurse staffing levels 503 that are above the minimum levels required in paragraphs (

a) and 504 (

b) based upon consideration of the following factors: 505 a. The number of patients and their acuity levels as 506 determined by the application of a patient classification system 507 on a shift-by-shift basis. 508 b. The anticipated admissions, discharges, and transfers of 509 patients during each shift which affect direct patient care. 510 c. The specialized experience required of direct care 511 registered nurses on a particular hospital unit or clinical 512 unit. 513 d.

Staffing levels of other health care personnel who 514 provide direct patient care services for patients who normally 515 do not require care by a direct care registered nurse. 516 e. The level of efficacy of technology that is available 517 that affects the delivery of direct patient care. 518 f. The level of familiarity with hospital practices, 519 policies, and procedures by a direct care registered nurse from 520 a temporary agency during a shift. 521 g. Obstacles to efficiency in the delivery of patient care 522

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 19 of 35 CODING: Words stricken are deletions; words underlined are additions. caused by the physical layout of the health care facility. 523 4. A health care facility shall specify the acuity-based 524 patient classification system used to document actual staffing 525 in each unit for each shift. 526 5. A health care facility shall annually evaluate: 527 a.

The reliability of the acuity-based patient 528 classification system for validating staffing requirements to 529 determine whether such system accurately measures individual 530 patient care needs and accurately predicts the staffing 531 requirements for direct care registered nurses, licensed 532 practical nurses, licensed psychiatric technicians, and 533 certified nursing assistants, based exclusively on individual 534 patient needs. 535 b. The validity of the acuity-based patient classification 536 system. 537 6.

A health care facility shall annually update its 538 staffing plan and acuity-based patient classification system to 539 the extent appropriate based on the annual evaluation conducted 540 under subparagraph 5. If the evaluation reveals that adjustments 541 are necessary to ensure accuracy in measuring patient care 542 needs, such adjustments must be implemented within 30 days after 543 such determination. 544 7.

Any acuity-based patient classification system adopted 545 by a health care facility under this subsection must be 546 transparent in all respects, including disclosure of detailed 547 documentation of the methodology used to predict nurse staffing; 548 an identification of each factor, assumption, and value used in 549 applying such methodology; an explanation of the scientific and 550 empirical basis for each such assumption and value; and 551

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 20 of 35 CODING: Words stricken are deletions; words underlined are additions. certification by a knowledgeable and authorized representative 552 of the health care facility that the disclosures regarding 553 methods used for testing and validating the accuracy and 554 reliability of such system are true and complete. 555 a.

The documentation required by this subparagraph shall be 556 submitted in its entirety to the agency as a mandatory condition 557 of licensure, with a certification by the chief nursing officer 558 of the health care facility that the documentation completely 559 and accurately reflects implementation of a valid acuity-based 560 patient classification system used to determine nurse staffing 561 by the facility for each shift in each hospital unit or clinical 562 unit in which patients receive care.

The chief nursing officer 563 shall execute the certification under penalty of perjury, and 564 the certification must contain an expressed acknowledgment that 565 any false statement constitutes fraud and is subject to criminal 566 and civil prosecution and penalties. 567 b. Such documentation must be available for public 568 inspection in its entirety in accordance with procedures 569 established by administrative rules adopted by the agency, 570 consistent with the purposes of this section. 571 8.

A staffing plan of a health care facility shall be 572 developed and evaluated by a committee created by the health 573 care facility. At least half of the members of the committee 574 must be unit-specific competent direct care registered nurses. 575 a. The chief nursing officer at the facility shall appoint 576 the members who are not direct care registered nurses. The 577 direct care registered nurses on the committee shall be 578 appointed by the chief nursing officer if the direct care 579 registered nurses are not represented by a collective bargaining 580

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 21 of 35 CODING: Words stricken are deletions; words underlined are additions. agreement or by an authorized collective bargaining agent. 581 b. In case of a dispute, the direct care registered nurse 582 assessment shall prevail. 583 c. This

section does not authorize conduct that is 584 prohibited under the National Labor Relations Act or the Federal 585 Labor Relations Act of 1978. 586 9. By July 1, 2021, the agency shall approve uniform 587 statewide standards for a standardized acuity tool for use in 588 health care facilities. The standardized acuity tool must 589 provide a method for establishing direct care registered nurse 590 staffing requirements that exceed the required direct care 591 registered nurse staffing levels in the hospital units or 592 clinical units in paragraphs (

a) and (b). 593 a. The proposed standards shall be developed by a committee 594 created by the health care facility consisting of up to 20 595 members. At least 11 of the committee members must be registered 596 nurses who are currently licensed and employed as direct care 597 registered nurses, and the remaining committee members must 598 include a sufficient number of technical or scientific experts 599 in specialized fields who are involved in the design and 600 development of an acuity-based patient classification system 601 that meets the requirements of this section. 602 b.

A person who has any employment or any commercial, 603 proprietary, financial, or other personal interest in the 604 development, marketing, or use of a private patient 605 classification system product or related methodology, 606 technology, or component system is not eligible to serve on the 607 committee. A candidate for appointment to the committee may not 608 be confirmed as a member until the candidate files a disclosure-609

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 22 of 35 CODING: Words stricken are deletions; words underlined are additions. of-interest statement with the agency, along with a signed 610 certification of full disclosure and complete accuracy under 611 oath, which provides all necessary information as determined by 612 the agency to demonstrate the absence of actual or potential 613 conflict of interest. All such filings are subject to public 614 inspection. 615 c.

Within 1 year after the official commencement of 616 committee operations, the committee shall provide a written 617 report to the agency which proposes uniform standards for a 618 valid, acuity-based patient classification system, along with a 619 sufficient explanation and justification to allow for competent 620 review and determination of sufficiency by the agency.

The 621 agency shall disclose the report to the public upon notice of 622 public hearings and provide a public comment period for proposed 623 adoption of uniform standards for an acuity-based patient 624 classification system by the agency. 625 10. A hospital shall adopt and implement the acuity-based 626 patient classification system and provide staffing based on the 627 standardized acuity tool. Any additional direct care registered 628 nurse staffing level that exceeds the direct care registered 629 nurse staffing levels described in paragraphs (

a) and (

b) shall 630 be assigned in a manner determined by such standardized acuity 631 tool. 632 11. A health care facility shall submit to the agency its 633 annually updated staffing plan and acuity-based patient 634 classification system as required under this paragraph. 635 (f)1. In each hospital unit or clinical unit, a health care 636 facility shall post a notice in a form specified by agency rule 637 which: 638

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 23 of 35 CODING: Words stricken are deletions; words underlined are additions. a. Explains the requirements imposed under this subsection; 639 b. Includes actual direct care registered nurse staffing 640 levels during each shift at the hospital unit or clinical unit; 641 c. Is visible, conspicuous, and accessible to staff and 642 patients of the hospital unit or clinical unit and the public; 643 d.

Identifies staffing requirements as determined by the 644 acuity-based patient classification system for each hospital 645 unit or clinical unit, documented and posted in the unit for 646 public view on a day-to-day, shift-by-shift basis; 647 e. Documents the actual number of staff and the skill mix 648 of such staff in each hospital unit or clinical unit, documented 649 and posted in the unit for public view on a day-to-day, shift-650 by-shift basis; and 651 f.

Reports the variance between the required and actual 652 staffing patterns in each hospital unit or clinical unit, 653 documented and posted in the unit for public view on a day-to-654 day, shift-by-shift basis. 655 2.a. A long-term acute care hospital shall maintain 656 accurate records of actual staffing levels in each hospital unit 657 or clinical unit for each shift for at least 2 years. Such 658 records must include: 659 (

I) The number of patients in each unit; 660 (II) The identity and duty hours of each direct care 661 registered nurse, licensed practical nurse, licensed psychiatric 662 technician, and certified nursing assistant assigned to each 663 patient in the hospital unit or clinical unit for each shift; 664 and 665 (III) A copy of each posted notice. 666 b. A health care facility shall make its staffing plan and 667

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 24 of 35 CODING: Words stricken are deletions; words underlined are additions. acuity-based patient classification system required under 668 paragraph (e), and all documentation related to such plan and 669 system, available to the agency; to direct care registered 670 nurses and their collective bargaining representatives, if any; 671 and to the public under rules adopted by the agency. 672 3.

The agency shall conduct periodic audits to ensure 673 implementation of the staffing plan in accordance with this 674 subsection and to ensure the accuracy of the staffing plan and 675 the acuity-based patient classification system required under 676 paragraph (e). 677 (

g) A health care facility shall plan for routine 678 fluctuations such as admissions, discharges, and transfers in 679 the patient census. If a declared state of emergency causes a 680 change in the number of patients in a unit, the health care 681 facility must demonstrate that immediate and diligent efforts 682 are made to maintain required staffing levels. 683 (

h) The following activities are prohibited: 684 1. The direct assignment of unlicensed personnel by a 685 health care facility to perform functions required of a direct 686 care registered nurse in lieu of care being delivered by a 687 licensed or registered nurse under the clinical supervision of a 688 direct care registered nurse. 689 2. The performance of patient care tasks by unlicensed 690 personnel which require the clinical assessment, judgment, and 691 skill of a licensed or registered nurse, including, but not 692 limited to: 693 a.

Nursing activities that require nursing assessment and 694 judgment during implementation; 695 b. Physical, psychological, or social assessments that 696

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 25 of 35 CODING: Words stricken are deletions; words underlined are additions. require nursing judgment, intervention, referral, or followup; 697 and 698 c.

Formulation of a plan of nursing care and evaluation of 699 a patient’s response to the care provided, including 700 administration of medication; venipuncture or intravenous 701 therapy; parenteral or tube feedings; invasive procedures, 702 including inserting nasogastric tubes, inserting catheters, or 703 tracheal suctioning; and educating a patient and the patient’s 704 family concerning the patient’s health care problems, including 705 postdischarge care.

However, a phlebotomist, emergency room 706 technician, or medical technician may, under the general 707 supervision of the clinical laboratory director, or his or her 708 designee, or a physician, perform venipunctures in accordance 709 with written hospital policies and procedures. 710

(4) PROFESSIONAL PRACTICE STANDARDS FOR DIRECT CARE 711 REGISTERED NURSES WORKING IN A HEALTH CARE FACILITY.— 712 (

a) A direct care registered nurse employing scientific 713 knowledge and experience in the physical, social, and biological 714 sciences, and exercising independent judgment in applying the 715 nursing process, shall directly provide: 716 1. Continuous and ongoing assessments of the patient’s 717 condition. 718 2. The planning, clinical supervision, implementation, and 719 evaluation of the nursing care provided to each patient. 720 3. The assessment, planning, implementation, and evaluation 721 of patient education, including the ongoing postdischarge 722 education of each patient. 723 4.

The delivery of patient care, which must reflect all 724 elements of the nursing process and must include assessment, 725

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 26 of 35 CODING: Words stricken are deletions; words underlined are additions. nursing diagnosis, planning, intervention, evaluation, and, as 726 circumstances require, patient advocacy, and shall be initiated 727 by a direct care registered nurse at the time of admission. 728 5.

The nursing plan for the patient care, which shall be 729 discussed with and developed as a result of coordination with 730 the patient, the patient’s family or other representatives, when 731 appropriate, and the staff of other disciplines involved in the 732 care of the patient. 733 6.

An evaluation of the effectiveness of the care plan 734 through assessments based on direct observation of the patient’s 735 physical condition and behavior, signs and symptoms of illness, 736 and reactions to treatment, and through communication with the 737 patient and the health care team members, and modification of 738 the plan as needed. 739 7.

Information related to the initial assessment and 740 reassessments of the patient, nursing diagnosis, plan, 741 intervention, evaluation, and patient advocacy, which shall be 742 permanently recorded in the patient’s medical record as 743 narrative direct care progress notes. The practice of charting 744 by exception is prohibited. 745 (b)1. A patient assessment requires direct observation of 746 the patient’s signs and symptoms of illness, reaction to 747 treatment, behavior and physical condition, and

interpretation 748 of information obtained from the patient and others, including 749 the health care team members. A patient assessment requires data 750 collection by a direct care registered nurse and the analysis, 751 synthesis, and evaluation of such data. 752 2. Only a direct care registered nurse may perform a 753 patient assessment. A licensed practical nurse or licensed 754

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 27 of 35 CODING: Words stricken are deletions; words underlined are additions. psychiatric technician may assist a direct care registered nurse 755 in data collection. 756 (c)1. A direct care registered nurse shall determine the 757 nursing care needs of individual patients through the process of 758 ongoing patient assessments, nursing diagnosis, formulation, and 759 adjustment of nursing care plans. 760 2.

The prediction of individual patient nursing care needs 761 for prospective assignment of direct care registered nurses 762 shall be based on individual patient assessments of the direct 763 care registered nurse assigned to each patient and in accordance 764 with a documented acuity-based patient classification system as 765 required in subsection (3). 766 (

d) Competent performance of the essential functions of a 767 direct care registered nurse as provided in this

section 768 requires the exercise of independent judgment in the exclusive 769 interests of the patient. A direct care registered nurse’s 770 independent judgment while performing the functions described in 771 this

section shall be provided in the exclusive interests of the 772 patient and may not, for any purpose, be considered, relied 773 upon, or represented as a job function, authority, 774 responsibility, or activity undertaken in any respect for the 775 purpose of serving the business, commercial, operational, or 776 other institutional interests of the health care facility 777 employer. 778 (e)1.

In addition to the prohibition on assignments of 779 patient care tasks provided in paragraph (3)(h), a direct care 780 registered nurse may not assign tasks required to implement 781 nursing care for a patient to other licensed nursing staff or to 782 unlicensed staff unless the assigning direct care registered 783

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 28 of 35 CODING: Words stricken are deletions; words underlined are additions. nurse: 784 a. Determines that the personnel assigned the nursing care 785 tasks possess the necessary training, experience, and capability 786 to competently and safely perform such tasks; and 787 b. Effectively supervises the clinical functions and 788 nursing care tasks performed by the assigned personnel. 789 2.

The exercise of clinical supervision of nursing care 790 personnel by a direct care registered nurse in the performance 791 of the functions as provided in this subsection must be in the 792 exclusive interests of the patient and may not, for any purpose, 793 be considered, relied upon, or represented as a job function, 794 authority, responsibility, or activity undertaken in any respect 795 for the purpose of serving the business, commercial, 796 operational, or other institutional interests of the health care 797 facility employer, but constitutes the exercise of professional 798 nursing authority and duty in the exclusive interests of the 799 patient. 800 (

f) A health care facility may not deploy technology that 801 limits the direct care provided by a direct care registered 802 nurse in the performance of functions that are part of the 803 nursing process, including the full exercise of independent 804 professional judgment in the assessment, planning, 805 implementation, and evaluation of care, or that limits a direct 806 care registered nurse from acting as a patient advocate in the 807 exclusive interests of the patient.

Technology may not be skill-808 degrading, interfere with the direct care registered nurse’s 809 provision of individualized patient care, or override the direct 810 care registered nurse’s independent professional judgment. 811 (

g) This subsection applies only to direct care registered 812

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 29 of 35 CODING: Words stricken are deletions; words underlined are additions. nurses employed by or providing care in a health care facility. 813

(5) DIRECT CARE REGISTERED NURSE’S DUTY AND RIGHT OF 814 PATIENT ADVOCACY.— 815 (

a) A direct care registered nurse has a duty and right to 816 act and provide care in the exclusive interests of the patient 817 and to act as the patient’s advocate. 818 (

b) A direct care registered nurse shall always provide 819 competent, safe, therapeutic, and effective nursing care to an 820 assigned patient. 821 1. Before accepting a patient assignment, a direct care 822 registered nurse must have the necessary knowledge, judgment, 823 skills, and ability to provide the required care.

It is the 824 responsibility of the direct care registered nurse to determine 825 whether he or she is clinically competent to perform the nursing 826 care required by a patient who is in a particular clinical unit 827 or who has a particular diagnosis, condition, prognosis, or 828 other determinative characteristic of nursing care, and whether 829 acceptance of a patient assignment would expose the patient to 830 the risk of harm. 831 2.

If the direct care registered nurse is not competent to 832 perform the care required for a patient assigned for nursing 833 care or if the assignment would expose the patient to risk of 834 harm, the direct care registered nurse may not accept the 835 patient care assignment. Such refusal to accept a patient care 836 assignment is an exercise of the direct care registered nurse’s 837 duty and right of patient advocacy. 838 (

c) A direct care registered nurse may refuse to accept an 839 assignment as a nurse in a health care facility if: 840 1. The assignment would violate

chapter 464 or rules 841

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 30 of 35 CODING: Words stricken are deletions; words underlined are additions. adopted thereunder; 842 2. The assignment would violate subsection (3), subsection 843 (4), or this subsection; or 844 3. The direct care registered nurse is not prepared by 845 education, training, or experience to fulfill the assignment 846 without compromising the safety of a patient or jeopardizing the 847 license of the direct care registered nurse. 848 (

d) A direct care registered nurse may refuse to perform an 849 assigned task as a nurse in a health care facility if: 850 1. The assigned task would violate

chapter 464 or rules 851 adopted thereunder; 852 2. The assigned task is outside the scope of practice of 853 the direct care registered nurse; or 854 3. The direct care registered nurse is not prepared by 855 education, training, or experience to fulfill the assigned task 856 without compromising the safety of a patient or jeopardizing the 857 license of the direct care registered nurse. 858 (

e) In the course of performing the responsibilities and 859 essential functions described in subsection (4), the direct care 860 registered nurse assigned to a patient shall receive orders 861 initiated by physicians and other legally authorized health care 862 professionals within their scope of licensure regarding patient 863 care services to be provided to the patient, including, but not 864 limited to, the administration of medications and therapeutic 865 agents that are necessary to implement a treatment, a 866 rehabilitative regimen, or disease prevention. 867 1.

The direct care registered nurse shall assess each such 868 order before implementation to determine if the order is: 869 a. In the exclusive interests of the patient; 870

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 31 of 35 CODING: Words stricken are deletions; words underlined are additions. b. Initiated by a person legally authorized to issue the 871 order; and 872 c. Issued in accordance with the applicable laws and rules 873 governing nursing care. 874 2.

If the direct care registered nurse determines that the 875 criteria provided in subparagraph 1. have not been satisfied 876 with respect to a particular order or if the direct care 877 registered nurse has some doubt regarding the meaning or 878 conformance of the order with such criteria, he or she shall 879 seek clarification from the initiator of the order, the 880 patient’s physician, or another appropriate medical officer 881 before implementing the order. 882 3.

If, upon clarification, the direct care registered nurse 883 determines that the criteria for implementation of an order 884 provided in subparagraph 1. have not been satisfied, the direct 885 care registered nurse may refuse implementation on the basis 886 that the order is not in the exclusive interests of the patient. 887 Seeking clarification of an order or refusing an order as 888 described in this subparagraph is an exercise of the direct care 889 registered nurse’s duty and right of patient advocacy. 890 (

f) A direct care registered nurse shall, as circumstances 891 require, initiate action to improve the patient’s health care or 892 to change a decision or activity that, in the professional 893 judgment of the direct care registered nurse, is against the 894 exclusive interests or desires of the patient or shall give the 895 patient the opportunity to make informed decisions about the 896 health care before it is provided. 897

(6) FREE SPEECH; PATIENT PROTECTION.— 898 (

a) A health care facility may not: 899

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 32 of 35 CODING: Words stricken are deletions; words underlined are additions. 1. Discharge, discriminate against, or retaliate against in 900 any manner with respect to any aspect of employment, including 901 discharge, promotion, compensation, or terms, conditions, or 902 privileges of employment, a direct care registered nurse based 903 on the direct care registered nurse’s refusal to accept an 904 assignment pursuant to paragraph (5)(

c) or an assigned task 905 pursuant to paragraph (5)(d). 906 2. File a complaint or a report against a direct care 907 registered nurse with the Board of Nursing or the agency because 908 of the direct care registered nurse’s refusal of an assignment 909 pursuant to paragraph (5)(

c) or an assigned task pursuant to 910 paragraph (5)(d). 911 (

b) A direct care registered nurse who has been discharged, 912 discriminated against, or retaliated against in violation of 913 subparagraph (a)1. or against whom a complaint or a report has 914 been filed in violation of subparagraph (a)2. may bring a cause 915 of action in a court of competent jurisdiction. A direct care 916 registered nurse who prevails in the cause of action is entitled 917 to one or more of the following: 918 1. Reinstatement. 919 2. Reimbursement of lost wages, compensation, and benefits. 920 3. Attorney fees. 921 4. Court costs. 922 5. Other damages. 923 (

c) A direct care registered nurse, a patient, or any other 924 individual may file a complaint with the agency against a health 925 care facility that violates this section. For any complaint 926 filed, the agency shall: 927 1. Receive and investigate the complaint; 928

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 33 of 35 CODING: Words stricken are deletions; words underlined are additions. 2. Determine whether a violation of this

section as alleged 929 in the complaint has occurred; and 930 3. If such a violation has occurred, issue an order 931 prohibiting the health care facility from subjecting the 932 complaining direct care registered nurse, the patient, or the 933 other individual to any retaliation described in paragraph (a). 934 (d)1.

A health care facility may not discriminate or 935 retaliate in any manner against any patient, employee, or 936 contract employee of the facility, or any other individual, on 937 the basis that such individual, in good faith, individually or 938 in conjunction with another person or persons, has presented a 939 grievance or complaint; initiated or cooperated in an 940 investigation or proceeding by a governmental entity, regulatory 941 agency, or private accreditation body; made a civil claim or 942 demand; or filed an action relating to the care, services, or 943 conditions of the health care facility or of any affiliated or 944 related facilities. 945 2.

For purposes of this paragraph, an individual is deemed 946 to be acting in good faith if the individual reasonably believes 947 that the information reported or disclosed is true. 948 (e)1. A health care facility may not: 949 a. Interfere with, restrain, or deny the exercise of, or 950 the attempt to exercise, any right provided or protected under 951 this section; or 952 b. Coerce or intimidate any person regarding the exercise 953 of, or the attempt to exercise, such right. 954 2.

A health care facility may not discriminate or retaliate 955 against any person for opposing any facility policy, practice, 956 or action that is alleged to violate, breach, or fail to comply 957

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 34 of 35 CODING: Words stricken are deletions; words underlined are additions. with this section. 958 3. A health care facility, or an individual representing a 959 health care facility, may not make, adopt, or enforce any rule, 960 regulation, policy, or practice that in any manner directly or 961 indirectly prohibits, impedes, or discourages a direct care 962 registered nurse from engaging in free speech or disclosing 963 information as provided under this section. 964 4.

A health care facility, or an individual representing a 965 health care facility, may not in any way interfere with the 966 rights of direct care registered nurses to organize, bargain 967 collectively, and engage in concerted activity under s. 7 of the 968 National Labor Relations Act. 969 5. A health care facility shall post in an appropriate 970 location in each hospital unit or clinical unit a notice in a 971 form specified by the agency which: 972 a. Explains the rights of nurses, patients, and other 973 individuals under this subsection; 974 b.

Includes a statement that a nurse, patient, or other 975 individual may file a complaint with the agency against a health 976 care facility that violates this subsection; and 977 c. Provides instructions on how to file a complaint. 978 (f)1. The agency shall establish a toll-free telephone 979 hotline to provide information regarding the requirements of 980 this

section and to receive reports of violations of this 981 section. 982 2. A health care facility shall provide each patient 983 admitted to the facility for inpatient care with the toll-free 984 telephone hotline described in subparagraph 1. and shall give 985 notice to each patient that the hotline may be used to report 986

Florida Senate - 2020 SB 204 35-00171-20 2020204__ Page 35 of 35 CODING: Words stricken are deletions; words underlined are additions. inadequate staffing or care. 987

(7) ENFORCEMENT.— 988 (

a) In addition to any other penalty prescribed by law, the 989 agency may impose civil penalties as follows: 990 1. Against a health care facility that violates this 991 section, a civil penalty of up to $25,000 for each violation, 992 except that the agency shall impose a civil penalty of at least 993 $25,000 for each violation if the agency determines that the 994 health care facility has a pattern of such violation. 995 2. Against an individual who is employed by a health care 996 facility who violates this section, a civil penalty of up to 997 $20,000 for each violation. 998 (

b) The agency shall post on its website the names of 999 health care facilities against which civil penalties have been 1000 imposed under this subsection and such additional information as 1001 the agency deems necessary. 1002

Section 3. This act shall take effect July 1, 2020. 1003