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    AN ACT concerning healthcare.

 
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    Be it enacted by the People of the State of Illinois,
 
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represented in the General Assembly:


 
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    Section 1. Short title. This Act may be cited as the 
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Nursing Care and Quality Improvement Act.
 
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    Section 5. Findings.  The Legislature finds and declares all 
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of the following:
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        (1)   The State of Illinois has a substantial interest in 
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    promoting quality care and improving the delivery of health 
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    care services to patients in health care facilities in the 
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    State.
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        (2)   Recent changes in the health care delivery systems 
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    that have resulted in higher acuity levels among patients 
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    in health care facilities increase the need for improved 
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    quality measures in order to protect patient care and 
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    reduce the incidence of medical errors.
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        (3)   Inadequate and poorly monitored registered nurse 
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    staffing practices that result in too few registered nurses 
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    providing direct care jeopardize the delivery of quality 
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    health care.
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        (4)   Numerous studies have shown that patient outcomes 
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    are directly correlated to direct care registered nurse 
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    staffing levels.
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        (5)   Requirements for direct care registered nurse 
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    staffing ratios will help address the registered nurse 
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    shortage in Illinois by aiding in recruitment of new 
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    registered nurses and improving retention of registered 
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    nurses who are considering leaving direct patient care 
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    because of the demands created by inadequate staffing.
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        (6)   Establishing adequate minimum direct care 
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    registered nurse-to-patient ratios that take into account 
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    patient acuity measures will improve the delivery of 
 


 






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    quality health care services and patient safety.
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        (7)   Establishing safe staffing standards for direct 
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    care registered nurses is a critical component of assuring 
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    that there is adequate hospital staffing at all levels to 
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    improve the delivery of quality care and protect patient 
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    safety.
 
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    Section 10. Definitions. In this Act:
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"Acuity system" means an established measurement tool that 
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does all of the following:
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        (1) predicts nursing care requirements for individual 
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    patients based on the severity of patient illness, the need 
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    for specialized equipment and technology, the intensity of 
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    nursing interventions required, and the complexity of 
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    clinical nursing judgment that is needed to design, 
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    implement, and evaluate the patient's nursing care plan;
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        (2) details the amount of nursing care needed, both in 
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    the number of nurses and in the skill mix of nursing 
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    personnel required, on a daily basis for each patient in a 
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    nursing department or unit;
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        (3) takes into consideration the patient care services 
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    provided not only by registered nurses but also by direct 
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    care licensed practical nurses and other health care 
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    personnel; and
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        (4) is stated in terms that can be readily used and 
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    understood by nurses.
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    "Nurse" and "registered nurse" means any person licensed as 
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a registered nurse or a registered professional nurse under the 
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Nursing and Advanced Practice Nursing Act.
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    "Direct care registered nurse" means an individual who has 
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been granted a license to practice as a registered nurse and 
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who provides bedside care for one or more patients.
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    "Director" means the Director of Public Health.


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    "Department" means the Department of Public Health.


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    "Employment" includes the provision of services under a 
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contract or other arrangement.
 


 






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    "Hospital" means an entity licensed under the Hospital 
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Licensing Act.
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    "Staffing plan" means a staffing plan required under 
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Section 15 of this Act.

 
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    Section 15. Staffing plan required. 
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    (a) Each hospital shall implement a staffing plan that (i) 
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provides adequate, appropriate, and quality delivery of health 
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care services, (ii) protects patient safety, and (iii) is 
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consistent with the requirements of this Act.
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    (b) Subject to Section 20 of this Act, the requirements of 
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subsection (a) shall take effect not later than one year after 
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the effective date of this Act.

 
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    Section 20. Minimum direct care registered 
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nurse-to-patient ratios. 

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    (a) For the purposes of this Section:
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    "Assigned" means the registered nurse has responsibility 
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for the provision of care to a particular patient within his or 
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her scope of practice.
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    "Assist" means that licensed nurses may provide patient 
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care beyond their patient assignments if the tasks performed 
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are specific and time-limited.
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    "Declared state-of-emergency" means a state-of-emergency 
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that has been declared by the federal government or the head of 
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the appropriate State or local governmental agency having 
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authority to declare that the State, county, municipality, or 
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locality is in a state-of-emergency, but does not include 
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consistent understaffing.
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    (b) A hospital's staffing plan shall provide that, during 
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each shift within a unit of the hospital, a direct care 
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registered nurse may be assigned to not more than the following 
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number of patients in that unit:
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        (1)  One patient in operating room units and trauma 
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    emergency units.
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        (2)  2 patients in critical care units, including 
 


 






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    emergency critical care and intensive care units, labor and 
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    delivery units, and post anesthesia units.
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        (3) 3 patients in ante partum units, emergency room 
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    units, pediatrics units, step-down units, and telemetry 
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    units.
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        (4)  4 patients in intermediate care nursery units, 
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    specialty care units, medical or surgical units, and acute 
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    care psychiatric units.
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        (5)  5 patients in rehabilitation units.


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        (6)  6 patients in postpartum (3 couplets) units and 
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    well-baby nursery units.
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    Registered nurse-to-patient ratios represent the maximum 
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number of patients who may be assigned to one registered nurse 
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at any one time. There shall be no averaging of the number of 
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patients and the total number of registered nurses on the unit 
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during any one shift nor over any period of time.  The 
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registered nurse-to-patient ratio must be maintained at all 
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times throughout each shift.  Only nurses providing direct 
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patient care shall be included in the ratios.

            
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    Staffing for care not requiring a registered nurse is not 
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included within these ratios.  Additional staff in excess of 
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these prescribed ratios, including non-licensed staff, shall 
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be assigned in accordance with the hospital's documented 
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patient acuity system for determining nursing care 
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requirements, considering factors that include the severity of 
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the illness, the need for specialized equipment and technology, 
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the complexity of clinical judgment needed to design, 
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implement, and evaluate the patient care plan, the ability for 
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self-care, and the licensure of the personnel required for 
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care.
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    Nurse administrators, nurse supervisors, nurse managers, 
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charge nurses, and other licensed nurses shall be included in 
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the calculation of the licensed nurse-to-patient ratio only 
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when those licensed nurses are engaged in providing direct 
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patient care. When a nurse administrator, nurse supervisor, 
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nurse manager, charge nurse, or other licensed nurse is engaged 
 


 






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in activities other than direct patient care, that nurse shall 
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not be included in the ratio. Nurse administrators, nurse 
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supervisors, nurse managers, and charge nurses who have 
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demonstrated current competence to the hospital in providing 
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care on a particular unit may relieve nurses during breaks, 
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meals, and other routine, expected absences from the unit.
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    (c) Nothing in this Section shall prohibit a nurse from 
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assisting with specific tasks within the scope of his or her 
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practice for a patient assigned to another nurse.
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    (d)  Within one year after the effective date of this Act, 
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the Department shall adopt rules providing specific guidance on 
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the implementation of the minimum direct care registered 
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nurse-to-patient ratios.  The Department shall adopt these 
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rules in accordance with the Department's licensing and 
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certification rules and other professional and vocational 
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rules under Illinois law.
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    (e) The Director may apply the minimum direct care 
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registered nurse-to-patient ratios established in subsection 
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(b) of this Section to a type of hospital unit not referred to 
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in that subsection (b) if that other unit performs a function 
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similar to the function performed by a unit referred to in 
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subsection (b).
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    (f)  If necessary to protect patient safety, the Director 
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may prescribe regulations that (i) increase minimum direct care 
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registered nurse-to-patient ratios under this Section to 
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further limit the number of patients that may be assigned to 
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each direct care nurse or (ii) add minimum direct care 
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registered nurse-to-patient ratios for units not referred to in 
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subsections (b) and (d). These regulations shall be prescribed 
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after consultation with affected hospitals and registered 
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nurses.
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    (g) The requirements established under this Section shall 
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not apply during a declared state-of-emergency, if a hospital 
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is requested or expected to provide an exceptional level of 
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emergency or other medical services.


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    (h) Nursing personnel from temporary nursing agencies 
 


 






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shall not be responsible for a patient care unit without having 
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demonstrated clinical and supervisory competence.
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    (i) The requirements of this Section shall take effect as 
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soon as practicable, as determined by the Director, but not 
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later than 2 years after the effective date of this Act.

 
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    Section 25. Development and reevaluation of staffing plan. 

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    (a) In developing a staffing plan, a hospital shall provide 
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for direct care registered nurse-to-patient ratios above the 
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minimum direct care registered nurse-to-patient ratios 
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required under Section 20 of this Act, if appropriate, based 
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upon consideration of all of the following factors:
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        (1)  the number of patients and acuity level of patients 
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    as determined by the application of an acuity system, on a 
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    shift-by-shift basis;
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        (2) the anticipated admissions, discharges, and 
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    transfers of patients during each shift that impacts direct 
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    patient care;
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        (3)  specialized experience required of direct care 
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    registered nurses on a particular unit;
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        (4)  staffing levels and services provided by other 
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    health care personnel in meeting direct patient care needs 
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    not required by a direct care registered nurse;
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        (5)  the level of technology available that affects the 
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    delivery of direct patient care;
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        (6)  the level of familiarity with hospital practices, 
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    policies, and procedures by temporary agency direct care 
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    registered nurses used during a shift; and
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        (7)  obstacles to efficiency in the delivery of patient 
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    care presented by physical layout.
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    (b) A hospital shall specify the system used to document 
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actual staffing in each unit for each shift.
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    (c)  A hospital shall annually evaluate (i) its staffing 
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plan in each unit in relation to actual patient care 
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requirements and (ii) the accuracy of its acuity system and 
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update its staffing plan and acuity system to the extent 
 


 






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appropriate based on the evaluation.
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    (d)  A staffing plan of a hospital shall be developed and 
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subsequent reevaluations shall be conducted under this Section 
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on the basis of input from direct care registered nurses at the 
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hospital or, if the nurses are represented through collective 
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bargaining, from the applicable recognized or certified 
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collective bargaining representative of the nurses.
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    (e) A hospital shall submit to the Director its staffing 
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plan and any annual updates under subsection (c).
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    (f) Nothing in this Act shall be construed to permit 
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conduct prohibited under the National Labor Relations Act or 
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under the Federal Labor Relations Act.
 
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    Section 30. Protection of nurses and other individuals. 

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    (a) A nurse may refuse to accept an assignment as a nurse 
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in a hospital if either of the following conditions apply:
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        (1) the assignment would violate the provisions of 
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    Sections 15, 20, or 25; or
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        (2) the nurse is not prepared by education, training, 
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    or experience to fulfill the assignment without 
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    compromising the safety of any patient or jeopardizing his 
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    or her license.
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    The requirements of this subsection (a) shall apply to 
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refusals occurring on or after the effective date of this Act, 
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except that the requirements of paragraph (2) of this 
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subsection (a) shall not apply to refusals in any hospital 
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before the requirements of Section 15 of this Act apply to that 
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hospital.
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    (b) No hospital shall discharge, discriminate, or 
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retaliate in any manner with respect to any aspect of 
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employment, including discharge, promotion, compensation, or 
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terms, conditions, or privileges of employment, against a nurse 
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based on the nurse's refusal of a work assignment under 
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subsection (a).  The requirements of this subsection (b) shall 
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apply to refusals occurring on or after the effective date of 
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this Act.
 


 






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    (c) No hospital shall file a complaint or a report against 
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a nurse with the appropriate State professional disciplinary 
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agency because of the nurse's refusal of a work assignment 
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under subsection (a). The requirements of this subsection (c) 
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shall apply to refusals occurring on or after the effective 
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date of this Act.
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    (d) Any nurse who has been discharged, discriminated, or 
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retaliated against, or against whom a complaint has been filed, 
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in violation of this Section may bring a cause of action in a 
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State court.  A nurse who prevails in the cause of action shall 
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be entitled to one or more of the following:
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        (1) Reinstatement.
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        (2) Reimbursement of lost wages, compensation, and 
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    benefits.
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        (3) Attorneys' fees.
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        (4) Court costs.
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        (5) Other damages.
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    The requirements of this subsection (d) shall apply to 
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refusals occurring on or after the effective date of this Act.
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    (e) A nurse or other individual may file a complaint with 
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the Director against a hospital that violates any provision of 
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this Act.  For any complaint filed, the Director shall do all of 
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the following:
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        (1) receive and investigate the complaint;
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        (2) determine whether a violation of this Act as 
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    alleged in the complaint has occurred; and
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        (3) if such a violation has occurred, issue an order 
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    that the complaining nurse or individual shall not suffer 
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    any retaliation under subsections (b), (c) or (f).
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    (f) A hospital shall not discriminate or retaliate in any 
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manner with respect to any aspect of employment, including 
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hiring, discharge, promotion, compensation, or terms, 
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conditions, or privileges of employment against any individual 
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who in good faith, individually, or in conjunction with another 
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person or persons, does any of the following:
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        (1) reports a violation or a suspected violation of 
 


 






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    this Act to the Director, a public regulatory agency, a 
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    private accreditation body, or the management personnel of 
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    the hospital;
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        (2) initiates, cooperates, or otherwise participates 
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    in an investigation or proceeding brought by the Director, 
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    a public regulatory agency, or a private accreditation body 
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    concerning matters covered by this Act; or
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        (3) informs or discusses with other individuals or with 
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    representatives of hospital employees a violation or 
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    suspected violation of this Act.
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    For the purposes of this subsection (f), an individual 
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shall be deemed to be acting in good faith if the individual  
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reasonably believes that the information reported or disclosed 
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is true and that a violation of this Act has occurred or may 
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occur.
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    The requirements of this subsection (f) shall apply to 
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those actions set forth in paragraphs (1) and (3) of this 
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subsection (f) and occurring on or after the effective date of 
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this Act.  The requirements of this subsection (f) shall apply 
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to initiation, cooperation, or participation in an 
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investigation or proceeding on or after the effective date of 
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this Act.
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    (g) Beginning 18 months after the effective date of this 
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Act, a hospital shall post in an appropriate location in each 
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unit a conspicuous notice in a form specified by the Director 
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that shall do each of the following:


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        (1) explain the rights of nurses and other individuals 
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    under this Section; and
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        (2) include a statement that a nurse or other 
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    individual may file a complaint with the Director against a 
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    hospital that violates the provisions of this Act and 
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    provide instructions on how to file this complaint.

 
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    Section 35. Penalties.   The Director may impose civil 
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penalties or suspend, revoke, or place conditional provisions 
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upon a license of a hospital for a violation of any provision 
 


 






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of this Act.  The Department shall adopt by rule a schedule 
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establishing the amount of civil penalty that may be imposed 
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for any violation of Sections 15, 20, 25, or 30 of this Act 
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when there is a reasonable belief that safe patient care has 
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been or may be negatively impacted.  Each violation of a 
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staffing plan shall be considered a separate violation.
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    In addition to any other monies set aside and appropriated 
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to the Department for nursing scholarships awarded pursuant to 
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the Nursing Education Scholarship Law, revenues collected from 
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fines incurred under this Act shall be allocated to the 
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Department for that same purpose.