HB 72 — NURSING STAFF-TO-PATIENT RATIOS IN HOSPITALS

c.230978.4 e s k 23 (1) for initial appointments, four members e a n b 24 shall serve for four-year terms, three members shall serve for u [ three-year terms, two members shall serve for two-year terms .228893.4 - 34 - andHJC/HB one72 memberC. shall serve for a one-year term;

(2)Term-length conditions for regularvoting appointmentsmembers afterappointed to the initialstatewide appointments,staffing four-yearadvisory terms;committee are:

(1) for initial appointments, five members shall serve for three-year terms, four members shall serve for two-year terms and four members shall serve for one-year terms;

(2) for regular appointments after the initial appointments, two-year terms;

The staffingauthority advisory committee shall electmake annuallyall ainitial chairappointments andto otherthe officersstatewide asstaffing theadvisory committee determinesby toSeptember be1, necessary.2025.

The statewide staffing advisory committee shall meetelect atother aofficers frequencyas necessary for the committee todetermines advise and provide data for the authority to usebe ine promulgatingt rules17 pursuantnecessary. to Section 3 of this 2025 act.

w l n d 18 F.

AThe majoritystatewide of the staffing advisory committee membersshall currently= serving= constitutes19 meet at a quorum.frequency necessary for the committee to advise and a l i a e r 20 provide data for the authority to use in promulgating rules a t m m 21 pursuant to Section 3 of this 2025 act.

The initial meeting of d r e t22 17the G.statewide staffing advisory committee shall occur no later c e s k 23 than October 1, 2025.

Thee authority may remove from office a member of w l n db 1824 theG. staffing advisory committee for neglect of duties." = = 19 a l SECTION 3.

A newmajority section of the Healthstatewide Carestaffing Codeadvisory isu i[ acommittee emembers rcurrently 20serving enactedconstitutes toa read:quorum.

a.230978.4 t- m5 m- 21HJC/HB "[NEW72 MATERIAL]H. HOSPITALS--LICENSED NURSE-TO-PATIENT d r e 22 RATIOS--AUTHORITY--COMMITTEE--POWERS AND DUTIES.-- c e s k 23 A.

The authority,authority withmay theremove advicefrom office a member of the statewide staffing eadvisory acommittee nfor bneglect 24of advisoryduties." committee,SECTION may:3.

uA [new (1)section ensureof that staffing ratios promulgated by .228893.4 - 4 - the authorityHealth areCare maintainedCode byis aenacted hospital;to read:

(2)"[NEW waiveMATERIAL] staffingHOSPITALS--LICENSED ratiosNURSE-TO-PATIENT forSTAFFING ruralRATIOS--AUTHORITY--COMMITTEE--POWERS generalAND acuteDUTIES.-- careA. hospitals as needed to increase operational efficiency;

providedEach thathospital doingor sohospital wouldnetwork notmay jeopardizeestablish a staffing committee or network staffing committee to evaluate the health,hospital's safetystaffing needs and well-beingmake ofstaffing patients;recommendations.

andEach (3)hospital seekthat injunctiveestablishes reliefa forstaffing violationscommittee ofor thisnetwork 2025staffing act.committee shall report the staffing committee's recommendations to the statewide staffing advisory committee for consideration.

ByThe July 1, 2026, the authority, with the advice of the statewide staffing advisory committee, shallmay: hold hearings and promulgate rules regarding:

e t 17 (1) minimum,ensure specificthat andlicensed numericalnurse-to-patient staffingw ratiosl forn hospitalsd licensed18 staffing ratios promulgated by the authority pursuantare tomaintained theby Health= Care= Code,19 whicha shallhospital; include:

(a)a licensedl nurse-to-patienti ratiosa bye r 20 (2) consider unlicensed personnel that provide a t m m 21 direct patient care as a factor when setting licensed nursenurse-to- classificationd andr hospitale unit;22 patient staffing ratios;

andc (b)e unlicenseds employee-to-patientk e23 t(3) 17waive ratioslicensed bynurse-to-patient unlicensedstaffing classificatione anda hospitaln unitb 24 ratios for wrural lgeneral nacute dcare 18and unlicensedcritical employeesaccess involvedu in[ directhospitals patientas care;needed to increase operational efficiency;

=.230978.4 =- 196 a- lHJC/HB (2)72 ruralprovided generalthat acutedoing careso hospitalwould staffingnot ijeopardize athe ehealth, rsafety 20and needs;well-being of patients;

providedand that(4) theseek ratiosinjunctive promulgatedrelief pursuantfor toviolations a t m m 21 Paragraph (1) of this subsection2025 mayact. be adjusted to accommodate d r e 22 these needs;

cC. e s k 23 (3) emergency department staffing, which shall e a n b 24 include the ratios provided pursuant to Paragraph (1) of this u [ subsection but shall distinguish between regularly scheduled .228893.4 - 5 - core staff licensed nurses and additional licensed nurses required to treat critical care patients;

andBy (4)October 1, 2026, the documentedauthority, patientwith classificationthe systemsadvice toof bethe usedstatewide bystaffing hospitalsadvisory incommittee, determiningshall nursinghold carehearings requirements,to includingpromulgate the:rules regarding:

(1) minimum, specific and numerical licensed nurse-to-patient staffing ratios for hospitals licensed by the authority pursuant to the Health Care Code, which shall include licensed nurse-to-patient staffing ratios by licensed nurse classification and hospital unit.

The authority may consider unlicensed personnel that provide direct patient care as a factor when setting licensed nurse-to-patient staffing ratios;

(2) rural general acute care and critical access hospital staffing needs;

provided that the ratios e t 17 promulgated pursuant to Paragraph (1) of this subsection may be w l n d 18 adjusted to accommodate these needs;

= = 19 (3) emergency department staffing, which shall a l i a e r 20 include the ratios provided pursuant to Paragraph (1) of this a t m m 21 subsection but shall distinguish between regularly scheduled d r e 22 core staff licensed nurses and additional licensed nurses c e s k 23 required to treat critical care patients.

The authority may e a n b 24 consider unlicensed personnel that provide direct patient care u [ as a factor when setting licensed nurse-to-patient staffing .230978.4 - 7 - HJC/HB 72 ratios;

(4) the documented patient classification systems to be used by hospitals in determining nursing care requirements, including the:

and (d) licensure of the personnel required for care.care;

C.and (5) circumstances in which it is permissible for a hospital to be outside of the established licensed nurse-to-patient staffing ratios, including:

Thee rulest promulgated17 by(a) when the authoritynumber pursuant to Subsection B of thispatients sectionin shalla not replace existing e t 17 nurse-to-patient ratios and unlicensed employee-to-patient w l n d 18 ratioshospital thatexceeds maythe existlicensed asnurse-to-patient providedstaffing byratios, rule or existing state or = = 19 abut lonly federaldue lawto asthere ofbeing thea effectivepatient dateor ofpatients thiswho: 2025 act.

1) have a l i a e r 20 D.been cleared for discharge but have not yet been discharged;

Theor authority, in consultation with the staffing a t m m 21 advisory2) committee,are shall:awaiting transfer to another facility;

d r e 22 (1)(b) reviewwhen thea rulesnurse adoptedcalls pursuantout toof a shift or c e s k 23 Subsectionmust Bleave of this section after five years following the e a nshift bearly; 24 adoption of the rules;

and e a n b 24 (c) the duration of time in which a u [ (2)hospital reportunit proposedmay rulesbe tooutside of the legislatureestablished .228893.4nurse-to- .230978.4 - 68 - priorHJC/HB 72 patient staffing ratios in one shift to promulgation."allow SECTIONtime 4.to bring in on-call nurses and unlicensed employees to meet the hospital unit's licensed nurse-to-patient staffing ratio.

AD. new section of the Health Care Code is enacted to read:

The rules promulgated by the authority pursuant to Subsection C of this section shall not replace existing nurse-to-patient staffing ratios and unlicensed employee-to- patient staffing ratios that may exist as provided by rule or existing state or federal law as of the effective date of this 2025 act.

E.

The authority, in consultation with the statewide staffing advisory committee, shall review the rules adopted pursuant to Subsection C of this section after five years following the adoption of the rules.

F.

The initial licensed nurse-to-patient staffing ratios established by the authority shall become effective no later than one hundred eighty days after the ratios are adopted e t 17 by rule;

provided that the licensed nurse-to-patient staffing w l n d 18 ratios established by the authority shall not apply to = = 19 emergency departments until at least eighteen months after the a l i a e r 20 initial ratios are adopted by rule;

and provided further that a t m m 21 an emergency department shall not be prevented from d r e 22 implementing the licensed nurse-to-patient staffing ratios c e s k 23 earlier than eighteen months after the initial ratios are e a n b 24 adopted by rule." u [ SECTION 4.

A new section of the Health Care Code is .230978.4 - 9 - HJC/HB 72 enacted to read:

(1) employbe staffstaffed at a level to meet the staffing ratios established by the authority, which shall be the minimum number of registered and licensed nurses and unlicensed employees involved in direct patient care;

and (2) adopt written policies and procedures for nursing staff and unlicensed employees involved in direct patient care and temporary personnel, which shall require:

(b) orientation for registered nurses e t 17 and unlicensed employees sufficient to provide competent care w l n d 18 to patients in a nursing unit or clinical area prior to =e =t 1917 a l assigning the registered nurse or unlicensed employees to those iw al en rd 2018 areas;

provided that the registered nurse or unlicensed a= t= m19 m 21 employee also demonstrates competency in providing care in the da rl i a e 22r 20 assigned area;

and ca et sm km 2321 (c) temporary personnel orientation and ed ar ne b22 24 competency evaluation.evaluation;

and c e s k 23 (3) submit a semiannual report, completed by e a n b 24 the hospital's chief nursing officer or director of nursing, to u [ B.the statewide advisory staffing committee and the authority.

A.230978.4 hospital- may10 employ- additionalHJC/HB staff72 inThe .228893.4report -shall 7document -the accordancehospital's withplans aand documentedefforts patientto classificationmeet system.staffing ratios recommended by the statewide staffing advisory committee.

B.

A hospital may have additional staff in accordance with a documented patient classification system.

(b) venipuncture or intravenous therapy;

(d) invasive procedures, including insertinge nasogastrict tubes,17 inserting cathetersnasogastric tubes and tracheal suctioning;

w l n d 18 (e) assessment of the condition of a = = 19 patient;

and a l i a e tr 1720 (f) educating patients and their wa lt nm dm 1821 families concerning the patient's health care problems, =d =r 19e a22 l including post-discharge care;care.

andc i a e rs 20k (g)23 moderateD. complexity laboratory a t m m 21 tests.

dAll rhospitals shall adopt written policies and e 22a D.n b 24 procedures for training and orientation of nursing staff and u [ unlicensed employees involved in direct patient care.

AllNo hospitals.230978.4 shall- adopt11 written- policiesHJC/HB and72 cregistered enurse sor kunlicensed 23employee proceduresinvolved forin trainingdirect andpatient orientationcare ofshall be assigned to a nursing staffunit andor eclinical aarea nunless bthat 24nurse or unlicensed employeesemployee involved in direct patient care.care has first received orientation in that clinical area sufficient to provide competent care to patients in that area and has demonstrated current competence in providing care in that area.

No u [ registered nurse or unlicensed employee involved in direct .228893.4 - 8 - patient care shall be assigned to a nursing unit or clinical area unless that nurse or unlicensed employee involved in direct patient care has first received orientation in that clinical area sufficient to provide competent care to patients in that area and has demonstrated current competence in providing care in that area.

e t 17 "[NEW MATERIAL] HOSPITAL STAFFING RATIOS--VIOLATION-- e t 17 ENFORCEMENT--REMEDIES.-- w l n d 18 ENFORCEMENT--REMEDIES.-- = = 19 a l A.

A hospital shall notprovide deviatewritten fromnotice anyto staffingthe =i =a 19e r 20 authority and the statewide staffing advisory committee a lt m m 21 whenever there are seven deviations from any staffing ratios d r e 22 established by the authority pursuant to this 2025 act iduring a c e rs 20k more23 than six times during a rolling thirty-dayninety-day period.

The awritten tnotice mshall: m 21 unit manager shall notify the staffing advisory committee and d r e 22 the authority no later than ten days after each deviation.

c e sa kn 23b Each24 subsequent(1) be provided within ten days of a seventh u [ deviation duringfrom the thirty-daystaffing periodratios eestablished aby nthe bauthority 24.230978.4 constitutes- a12 separate- violation.HJC/HB 72 pursuant to this 2025 act;

u(2) [explain B.the cause of the deviations;

Theand authority(3) shall,provide no later than July 1, 2026, .228893.4 - 9 - adopt rules that establish a processplan forto investigatingprevent andfuture remedyingdeviations. any violation of hospital staffing requirements.

TheB. rules shall specify reporting requirements for deviations consistent with this section and allow for the acceptance, investigation and resolution of complaints from hospital staff, exclusive representatives of hospital staff or members of the public.

C.No later than October 1, 2026, the authority, with the advice of the statewide staffing advisory committee, shall hold a hearing to promulgate rules that establish a process for investigating and remedying any violation of hospital staffing requirements.

IfThe therules authority determines, whether through a complaint process, hospital reporting or the authority's own independent investigation, that a hospital has engaged in a violation of staffing requirements, the authority shall:

(1) issuespecify areporting warningrequirements for thedeviations firstconsistent violationwith inthis asection; four-year period;

(2) imposeallow afor civilthe penaltyacceptance, ofinvestigation oneand thousandresolution sevenof hundredcomplaints fiftyfrom dollarshospital ($1,750)staff, forexclusive therepresentatives second violation of thehospital samestaff provisionor inmembers aof four-yearthe period;public;

eand t 17 (3) imposeprovide aan civiladministrative penaltyappeals ofprocess twofor thousandhospitals wthat lare ndetermined dby 18the fiveauthority hundredto dollarsbe ($2,500)in fore thet third17 violation of the =hospital =staffing 19requirements. a l same provision in a four-year period;

andA ihospital aw el rn 20d (4)18 imposeshall ahave civilthe penaltyright ofto fivejudicial thousandreview aof tany mfinal mdecision 21= dollars= ($5,000)19 formade theby fourth and subsequent violations of d r e 22 the sameauthority provisionpursuant into athis four-yearsection. period.

ca el si ka 23e D.r 20 C.

If the authority findsdetermines, thatwhether through a hospitala hast em am n21 bcomplaint 24process, committedhospital multiplereporting violationsor of the staffingauthority's ratioown ud [r requirementse of22 aindependent similarinvestigation, nature,that ita shallhospital requirehas theengaged hospitalin .228893.4a -c 10e -s tok submit23 aviolation correctiveof actionstaffing planrequirements, forthe approval.authority shall:

Ife a hospitaln doesb not24 follow(1) theissue correctivea actionwarning planfor approved by the authority,first theviolation hospitalin shallu be[ fineda fiftyone-year thousandperiod; dollars ($50,000) every thirty days until the hospital complies.

E..230978.4 - 13 - HJC/HB 72 (2) impose a civil penalty not to exceed one thousand seven hundred fifty dollars ($1,750) for the second violation of the same provision in a one-year period;

The(3) requirementsimpose ofa thiscivil sectionpenalty ornot any rules adopted pursuant to thisexceed 2025two actthousand mayfive behundred enforceddollars by($2,500) a civil action brought by any interested person or organization for injunctivethe reliefthird toviolation enforceof the provisionssame ofprovision thisin sectiona orone-year anyperiod; rules adopted hereunder.

Inand the(4) eventimpose such a suitcivil ispenalty atnot leastto partiallyexceed successful,five thethousand courtdollars may($5,000) awardfor the interestedfourth personand orsubsequent organizationviolations litigationof coststhe andsame reasonableprovision attorneyin fees.a one-year period.

F.D.

If the authority finds that a hospital has committed multiple violations of the staffing ratio requirements of a similar nature, it shall require the hospital to submit a corrective action plan for approval.

If a hospital does not follow the corrective action plan approved by the authority, the hospital shall be fined in an amount not to exceed fifty thousand dollars ($50,000) every thirty days until e t 17 the hospital complies.

w l n d 18 E.

The requirements of this section or any rules = = 19 adopted pursuant to this 2025 act may be enforced by a civil a l i a e r 20 action brought by any interested person or organization for a t m m 21 injunctive relief to enforce the provisions of this section or d r e 22 any rules adopted hereunder.

In the event such a suit is at c e s k 23 least partially successful, the court may award the interested e a n b 24 person or organization litigation costs and reasonable attorney u [ fees.

.230978.4 - 14 - HJC/HB 72 F.

e t 17 (2) sudden and unforeseen adverse weather w l n d 18 conditions;

or = = 19 a l (3) anmass infectiouscasualty diseaseincidents; epidemic suffered by i a e r 20 hospital staff.

a(4) tpandemic, mepidemic mor 21endemic G.illnesses;

The(5) authoritycircumstances maythat grantmake waiversstaffing toratio ruralrequirements unreasonable or dunattainable rdue eto 22limitations criticalin access hospitals for portions of this 2025 act if the cworkforce; e s k 23 hospital is able to document reasonable efforts to obtain e a n b 24 adequate staff." u [ SECTION 6.

EMERGENCY.--Itor is(6) necessarya forstaffing theratio publicconflicting .228893.4with -federal 11or -state peace,law healthregarding andthe safetygovernance thatrequirements thisof acta takehospital. effect immediately.

-G. 12 - 4 6 8 10 12 14 16 e t 17 w l n d 18 = = 19 a l i a e r 20 a t m m 21 d r e 22 c e s k 23 e a n b 24 u [ .228893.4

The authority may grant waivers to rural or critical access hospitals for portions of this 2025 act if the e t 17 hospital is able to document reasonable efforts to obtain w l n d 18 adequate staff." = = 19 - 15 - a l i a e r 20 a t m m 21 d r e 22 c e s k 23 e a n b 24 u [ .230978.4