00 SENATE BILL NO. 283 01 "An Act relating to staffing standards for registered nurses; and providing for an 02 effective date." 03 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF ALASKA: 04  * Section 1. AS 18.20 is amended by adding new sections to read: 05 Article 2A. Hospital Registered Nurse Staffing.  06 Sec. 18.20.265. Registered nurse minimum staffing standards for  07 hospitals. (a) A hospital shall comply with the registered nurse minimum staffing 08 standards established in this section. 09 (b) The maximum number of patients each registered nurse may be assigned 10 during a shift is as follows: 11 (1) in an emergency department, four patients or, if an assigned patient 12 will be admitted as an in-patient in another unit, the lowest maximum number of 13 patients permitted in that unit; a registered nurse may not be assigned more than one 14 trauma or critical care patient; 01 (2) in an intensive care unit, 02 (A) two patients; or 03 (B) one patient, if the patient is assessed as a high acuity 04 patient; 05 (3) in a labor and delivery unit, 06 (A) two patients; or 07 (B) one patient, if the patient is in active labor or is in any stage 08 of labor and experiencing complications; 09 (4) in a postpartum or antepartum unit or well-baby nursery, six 10 patients; for the purpose of this paragraph, each mother and each baby is a separate 11 patient; 12 (5) in an operating room, one patient; 13 (6) in an oncology unit, four patients; 14 (7) in a post-anesthesia care unit, two patients; 15 (8) in a progressive care or step-down unit, four patients; 16 (9) in an intermediate specialty care unit, three patients; 17 (10) in a medical-surgical unit, four patients; 18 (11) in a telemetry unit, four patients; 19 (12) in a psychiatric unit, 20 (A) four patients; or 21 (B) fewer than four patients, as determined by the hospital's 22 registered nurse staffing standards, if an assigned patient 23 (i) requires one-on-one observation; 24 (ii) is in an acute-manic phase; 25 (iii) is volatile; 26 (iv) is physically compromised; or 27 (v) is assessed as a high acuity patient; 28 (13) in a pediatrics unit, four patients; and 29 (14) in an in-patient hemodialysis unit, one patient. 30 (c) The registered nurse staffing standards established in this section are based 31 on the type of care provided in a patient care unit, regardless of the specific name or 01 reference used by the hospital for the unit. 02 (d) A hospital may not average the number of patients or the total number of 03 registered nurses assigned to patients in a patient care unit during a single shift or over 04 any period to meet the registered nurse staffing standards established in this section. 05 (e) A hospital may not include a registered nurse in charge of coordinating 06 patient care responsibilities among nurses, a coordinator of patient care flow, or a 07 persona generated by artificial intelligence or other nonhuman persona in meeting the 08 registered nurse staffing standards. Registered nurses who are working remotely or 09 virtually and are not physically present in the hospital department may not be included 10 to meet the registered nurse staffing standards. 11 (f) Before a registered nurse may be assigned to a patient care unit or clinical 12 area, the registered nurse must have received an orientation in the clinical area 13 sufficient to demonstrate current competence in providing care in the area. 14 (g) Nothing in this section precludes a hospital from assigning fewer patients 15 to a registered nurse than the maximum determined in the staffing standards 16 established in this section. 17 Sec. 18.20.270. Registered nurse staffing plans for hospitals. (a) A hospital 18 shall have a registered nurse staffing plan. The registered nurse staffing plan must 19 include minimum staffing levels for each unit in the hospital, including 20 (1) the number of registered nurses employed in each care unit in the 21 hospital required to meet the registered nurse minimum staffing standards established 22 in AS 18.20.265; 23 (2) the minimum registered nurse skill mix for each patient care unit in 24 the hospital, including in-patient, critical care, and emergency units; and 25 (3) the number of supportive direct patient care personnel required to 26 be assigned to each patient care unit and the classification of each supportive direct 27 patient care personnel member assigned to a patient care unit. 28 (b) A hospital shall include the following in the hospital's registered nurse 29 staffing plan: 30 (1) a patient acuity classification system for determining the nursing 31 care needs of an individual patient; 01 (2) a written certification that the registered nurse staffing plan is 02 sufficient to provide adequate, appropriate, and safe delivery of health care services to 03 patients during the year; 04 (3) the hospital's employment practices concerning the use of 05 temporary and travel nurses; and 06 (4) the hospital's process for internal review of the registered nurse 07 staffing plan. 08 (c) A hospital's registered nurse staffing plan must be approved by a majority 09 vote of the members of the hospital's staffing committee. 10 (d) A hospital shall post the hospital's registered nurse staffing plan in a 11 location in each unit of the hospital that is visible, conspicuous, and accessible to staff, 12 patients, and the public. 13 (e) The department shall post each hospital's registered nurse staffing plan on 14 the department's Internet website. 15 (f) A hospital may not reduce the level of supportive direct patient care 16 personnel established in a hospital's registered nurse staffing plan or a collective 17 bargaining agreement. 18 Sec. 18.20.275. Variances. (a) A hospital may deviate from the registered 19 nurse minimum staffing standards established in AS 18.20.265 or the hospital's 20 registered nurse staffing plan required by AS 18.20.270 in the following 21 circumstances: 22 (1) an unforeseen emergency situation that could jeopardize patient 23 safety; in this paragraph, "unforeseen emergency situation" has the meaning given in 24 AS 18.20.400(c)(3)(B); 25 (2) a scheduling problem caused by unforeseen weather conditions that 26 prevent a second nurse from arriving at the hospital to relieve the nurse on duty; in this 27 paragraph, "unforeseen weather conditions" has the meaning given in 28 AS 18.20.400(c)(3)(C); 29 (3) the hospital is located in a rural community and declares a 30 temporary nurse staffing emergency under AS 18.20.410. 31 (b) Within 30 days after a hospital deviates from a written registered nurse 01 staffing plan under circumstances outlined in (a)(1) or (2) of this section, the hospital 02 shall report the deviation to the staffing committee along with an assessment of the 03 staffing needs arising from the circumstances. A deviation from the written registered 04 nurse staffing plan may continue for longer than 90 days only upon a majority vote by 05 the staffing committee approving the deviation. 06 Sec. 18.20.280. Staffing committees for hospitals. (a) A hospital shall 07 maintain a staffing committee to prepare the hospital's registered nurse staffing plan. 08 (b) At least 51 percent of the staffing committee members must be registered 09 nurses who are employed by the hospital in a nonsupervisory capacity and whose 10 primary responsibility is to provide direct patient care. For a hospital in which 11 registered nurses are part of a collective bargaining unit, the representative of the 12 collective bargaining unit shall appoint the registered nurse members of the staffing 13 committee. If the hospital's registered nurses are not part of a collective bargaining 14 unit, the registered nurse members of the staffing committee shall be selected by peers 15 of the registered nurses. 16 (c) At least one member of the staffing committee must be a supportive direct 17 patient care personnel member employed by the hospital in a nonsupervisory and 18 nonmanagerial capacity. For a hospital in which supportive direct patient care 19 personnel are part of a collective bargaining unit, the representative of the collective 20 bargaining unit shall appoint the supportive direct patient care personnel of the 21 staffing committee. If the hospital's supportive direct patient care personnel are not 22 part of a collective bargaining unit, the supportive direct patient care personnel 23 members shall be selected by peers of the supportive direct patient care personnel. 24 (d) The remainder of the members of the staffing committee shall be 25 appointed by the hospital administration. The staffing committee must include the 26 hospital's chief financial officer, chief nursing officer, and patient care unit directors or 27 managers, or designees of the officers, directors, or managers. 28 (e) A hospital shall release each member of the staffing committee from the 29 member's assignment and ensure adequate staffing to cover the member's assignment 30 so that the member can participate in staffing committee meetings. The hospital shall 31 pay each member the member's regular rate of pay, including any differentials, for 01 time spent at committee meetings. Time spent at committee meetings constitute hours 02 worked for the purpose of payment of overtime wages. 03 (f) If less than all the committee members are present, the committee may take 04 action if least 51 percent of the members present are registered nurses and supportive 05 direct patient care personnel appointed under (b) and (c) of this section. 06 (g) A hospital may not retaliate, discriminate, or take any other adverse action 07 against an employee or any aspect of an employee's employment, including discharge, 08 demotion, reduction in compensation, or changes to terms, conditions, or privileges of 09 employment, because of the employee's participation in the staffing committee or 10 because the employee files a report or complaint or otherwise raises concerns 11 regarding unsafe staffing. 12 (h) A registered nurse, collective bargaining representative, if applicable, 13 patient, or other person may file a report or complaint with the staffing committee 14 about an assignment in a patient care unit that deviates from the hospital's staffing 15 plan. A hospital shall include any report or complaint filed with the staffing committee 16 in the hospital's quarterly report to the department required by AS 18.20.285. 17 (i) The department shall develop a process for issuing a corrective plan of 18 action to a hospital that fails to meet the hospital's registered nurse staffing plan 19 required by AS 18.20.270 or that fails to meet the registered nurse minimum staffing 20 standards established in AS 18.20.265. If the department determines, through regular 21 reporting or review of complaints, that a hospital has been out of compliance with the 22 hospital's registered nurse staffing plan or staffing standards, the department shall 23 issue a corrective plan of action within 30 days after the department presents its 24 findings to the hospital. Failure to comply with a corrective plan of action may result 25 in a civil penalty in accordance with AS 18.20.290. 26 Sec. 18.20.285. Tracking, reporting, and compliance. (a) By October 1 of 27 each year, a hospital shall provide to the department, through a process determined by 28 the department, the hospital's registered nurse staffing plan for the following calendar 29 year. A hospital shall notify the department each time the registered nurse staffing 30 plan is updated. 31 (b) Not later than the last business day of the month following each quarter, a 01 hospital shall submit a quarterly report to the department. The quarterly report must 02 include 03 (1) each date the hospital failed to meet the requirements of the 04 registered nurse staffing plan established in AS 18.20.270, the unit in which the failure 05 occurred, the classification of each patient care provider not adequately staffed, and 06 the staffing levels for that classification; and 07 (2) any report or complaint filed with the staffing committee. 08 (c) If a hospital has not submitted a registered nurse staffing plan to the 09 department, the quarterly report must include 10 (1) each date the hospital failed to meet the registered nurse minimum 11 staffing standards established in AS 18.20.265, the unit in which the failure occurred, 12 the classification of each patient care provider not adequately staffed, and the staffing 13 levels for that classification; and 14 (2) any report or complaint filed with the staffing committee. 15 Sec. 18.20.290. Civil penalties. (a) In accordance with regulations adopted by 16 the department under AS 44.62.010 - 44.62.305, the department may assess and 17 collect a civil penalty of 18 (1) $10,000 for each day a hospital with 100 beds or more, or $2,500 19 for each day a hospital with fewer than 100 beds, is found to be in violation of 20 AS 18.20.285(a); 21 (2) $5,000 for each business day a hospital with 100 beds or more, or 22 $1,000 for each business day a hospital with fewer than 100 beds, is found to be in 23 violation of AS 18.20.285(b) or (c); 24 (3) $5,000 for each violation for which a hospital with 100 beds or 25 more, or $1,000 for each violation for which a hospital with fewer than 100 beds, is 26 found to have failed to follow a corrective plan issued under AS 18.20.280(i). 27 (b) The department may use any remedy available under law to collect an 28 unpaid civil penalty for a violation of AS 18.20.265 - 18.20.295. 29 Sec. 18.20.295. Definitions. In AS 18.20.265 - 18.20.295, 30 (1) "acuity" means the level of a patient's need for nursing care, as 31 determined by a nursing assessment; 01 (2) "department" means the Department of Health; 02 (3) "direct care" means care that is delivered directly to patients, not 03 telephonically or virtually; 04 (4) "hospital" has the meaning given in AS 18.20.130; 05 (5) "intensive care unit" includes a critical care unit, special care unit, 06 coronary care unit, pediatric intensive care unit, neonatal intensive care unit, 07 neurological critical care unit, burn unit, or any unit within a hospital that provides 08 specialized care to a patient with a life-threatening illness or injury that requires 09 continuous monitoring and treatment 24 hours a day; 10 (6) "registered nurse" has the meaning given to "licensed registered 11 nurse" in AS 08.68.850; 12 (7) "skill mix" means the experience levels and number of nursing and 13 ancillary health personnel; 14 (8) "staffing committee" means the staffing committees for hospitals 15 established in AS 18.20.280; 16 (9) "supportive direct patient care personnel" includes nurse aides, 17 orderlies, assistants, technicians, mental health professionals or associates, or other 18 persons who provide direct care to patients. 19  * Sec. 2. The uncodified law of the State of Alaska is amended by adding a new section to 20 read: 21 TRANSITION. A hospital subject to AS 18.20.285, enacted by sec. 1 of this Act, shall 22 implement its initial registered nurse staffing plan on or before January 1, 2027. 23  * Sec. 3. This Act takes effect immediately under AS 01.10.070(c).