1. Legislative intent. The legislature hereby finds and declares:

1. (a) Research demonstrates that nurses play a critical role in improving patient safety and quality of care;
2. (b) Appropriate staffing of general hospital personnel, including registered nurses available for patient care, assists in reducing errors, complications and adverse patient care events, improves staff safety and satisfaction, and reduces incidences of workplace injuries;
3. (c) Health care professional, technical, and support staff comprise vital components of the patient care team, bringing their particular skills and services to ensuring quality patient care;
4. (d) Ensuring sufficient staffing of general hospital personnel, including registered nurses, is an urgent public policy priority in order to protect patients and support greater retention of registered nurses and safer working conditions; and
5. (e) It is the public policy of the state to promote evidence-based nurse staffing standards and increase transparency of health care data and decision making based on the data.

4. Primary responsibilities. Primary responsibilities of the clinical staffing committee shall include the following functions:

1. (a) Development and oversight of implementation of an annual clinical staffing plan. The clinical staffing plan shall include specific staffing for each patient care unit and work shift and shall be based on the needs of patients. Staffing plans shall include specific guidelines or ratios, matrices, or grids indicating how many patients are assigned to each registered nurse and the number of nurses and ancillary staff to be present on each unit and shift and shall be used as the primary component of the general hospital staffing budget.

2. (b) Factors to be considered and incorporated in the development of the plan shall include, but are not limited to:

   1. (i) Census, including total numbers of patients on the unit on each shift and activity such as patient discharges, admissions, and transfers;
   2. (ii) Measures of acuity and intensity of all patients and nature of the care to be delivered on each unit and shift;
   3. (iii) Skill mix;
   4. (iv) The availability, level of experience, and specialty certification or training of nursing personnel providing patient care, including charge nurses, on each unit and shift;
   5. (v) The need for specialized or intensive equipment;
   6. (vi) The architecture and geography of the patient care unit, including but not limited to placement of patient rooms, treatment areas, nursing stations, medication preparation areas, and equipment;
   7. (vii) Mechanisms and procedures to provide for one-to-one patient observation, when needed, for patients on psychiatric or other units as appropriate;
   8. (viii) Other special characteristics of the unit or community patient population, including age, cultural and linguistic diversity and needs, functional ability, communication skills, and other relevant social or socio-economic factors;
   9. (ix) Measures to increase worker and patient safety, which could include measures to improve patient throughput;
   10. (x) Staffing guidelines adopted or published by other states or local jurisdictions, national nursing professional associations, specialty nursing organizations, and other health professional organizations;
   11. (xi) Availability of other personnel supporting nursing services on the unit;
   12. (xii) Waiver of plan requirements in the case of unforeseeable emergency circumstances as defined in subdivision fourteen of this section;
   13. (xiii) Coverage to enable registered nurses, licensed practical nurses, and ancillary staff to take meal and rest breaks, planned time off, and unplanned absences that are reasonably foreseeable as required by law or the terms of an applicable collective bargaining agreement, if any, between the general hospital and a representative of the nursing or ancillary staff;
   14. (xiv) The nursing quality indicators required under subdivision seventeen of this section;
   15. (xv) General hospital finances and resources; and
   16. (xvi) Provisions for limited short-term adjustments made by appropriate general hospital personnel overseeing patient care operations to the staffing levels required by the plan, necessary to account for unexpected changes in circumstances that are to be of limited duration.
3. (c) Semiannual review of the staffing plan against patient needs and known evidence-based staffing information, including the nursing sensitive quality indicators collected by the general hospital.
4. (d) Review, assessment, and response to complaints regarding potential violations of the adopted staffing plan, staffing variations, or other concerns regarding the implementation of the staffing plan and within the purview of the committee.

(b) The clinical staffing plan shall comply with applicable laws and regulations, including, but not limited to:

1. (i) Regulations made by the department on burn unit staffing, liver transplant staffing, and operating room circulating nurse staffing;
2. (ii) Staffing regulations to be promulgated by the commissioner relating to staffing in intensive care and critical care units no later than January first, two thousand twenty-two. Such regulations shall consider the factors set forth in paragraph (b) of subdivision four of this section, standards in place in neighboring states, and a minimum standard of twelve hours of registered nurse care per patient per day;
3. (iii) Such other staffing standards or regulations as are currently in effect or may hereafter be established by the department or enacted by the legislature; and
4. (iv) The provisions of section one hundred sixty-seven of the labor law and any related regulations.

9. Retaliation and intimidation prohibited. A general hospital shall not retaliate against or engage in any form of intimidation of:

1. (a) An employee for performing any duties or responsibilities in connection with the clinical staffing committee; or
2. (b) An employee, patient, or other individual who notifies the clinical staffing committee or the hospital administration of the individual's staffing concerns.

11. Investigations. (a) The department shall investigate potential violations of this section following receipt of a complaint with supporting evidence, of failure to:

1. (i) Form or establish a clinical staffing committee;
2. (ii) Comply with the requirements of this section in creating a clinical staffing plan;
3. (iii) Adopt all or part of a clinical staffing plan that is approved by consensus of the clinical staffing committee and submitted to the department;
4. (iv) Conduct a semiannual review of a clinical staffing plan; or
5. (v) Submit to the department a clinical staffing plan on an annual basis and any updates.
6. (b) The department shall initiate an investigation of unresolved complaints, that have first been submitted to the clinical staffing committee, regarding compliance with the clinical staffing plan, personnel assignments in a patient care unit or staffing levels, or any other requirement of the adopted clinical staffing plan, excluding complaints determined by the clinical staffing committee to be resolved or dismissed as determined by consensus of the clinical staffing committee as described in paragraph (b) of subdivision six of this section.
7. (c) The department shall initiate an investigation after making an assessment that there is a pattern of failure to resolve complaints submitted to the clinical staffing committee or a pattern of failure to reach consensus on the adoption of all or part of a clinical staffing plan. In the case of a pattern of failure to resolve complaints or to reach consensus on the adoption of all or part of a clinical staffing plan, the department shall determine if the pattern was due to one of the parties routinely refusing to resolve complaints or reach consensus.
8. (d) Any department investigation of a complaint under this subdivision shall consider whether unforeseeable emergency circumstances as defined in subdivision fourteen of this section contributed to the failure of the general hospital to comply with this section.
9. (e) After an investigation conducted under paragraph (a) or (b) of this subdivision, if the department determines that there has been a violation, the department shall require the general hospital to submit a corrective plan of action within forty-five days of the presentation of findings from the department to the hospital. If the department determines after investigation under paragraph (c) of this subdivision that the general hospital representatives on the clinical staffing committee were responsible for a pattern of not resolving complaints or for a pattern of not reaching consensus, the department shall require the general hospital to submit a corrective action plan within forty-five days of the presentation of findings to the general hospital. If the department finds that the frontline staff representatives on the clinical staffing committee were responsible for a pattern of not resolving complaints or for a pattern of not reaching consensus, the department shall not require the general hospital to submit a corrective action plan or impose a civil penalty on the general hospital pursuant to subdivision twelve of this section.

14. Unforeseeable emergency circumstances. (a) For purposes of this section, "unforeseeable emergency circumstance" means:

1. (i) Any officially declared national, state, or municipal emergency;
2. (ii) When a general hospital disaster plan is activated; or
3. (iii) Any unforeseen disaster or other catastrophic event that immediately affects or increases the need for health care services.
4. (b) In determining whether a general hospital has violated its obligations under this section to comply with the general hospital's clinical staffing plan, it shall not be a defense that it was unable to secure sufficient staff if the lack of staffing was foreseeable and could be prudently planned for or involved routine nurse staffing needs that arose due to typical staffing patterns, typical levels of absenteeism, and time off typically approved by the employer for vacation, holidays, sick leave, and personal leave.

17. Disclosure of nursing quality indicators. (a) Every facility with an operating certificate pursuant to the requirements of this article shall make available to the public information regarding nurse staffing and patient outcomes as specified by the commissioner by rule and regulation. The commissioner shall promulgate rules and regulations on the disclosure of nursing quality indicators providing for the disclosure of information including at least the following, as appropriate to the reporting facility:

1. (i) The number of registered nurses providing direct care and the ratio of patients per registered nurse, full-time equivalent, providing direct care. This information shall be expressed in actual numbers, in terms of total hours of nursing care per patient, including adjustment for case mix and acuity, and as a percentage of patient care staff, and shall be broken down in terms of the total patient care staff, each unit, and each shift.
2. (ii) The number of licensed practical nurses providing direct care. This information shall be expressed in actual numbers, in terms of total hours of nursing care per patient including adjustment for case mix and acuity, and as a percentage of patient care staff, and shall be broken down in terms of the total patient care staff, each unit, and each shift.
3. (iii) The number of unlicensed personnel utilized to provide direct patient care, including adjustment for case mix and acuity. This information shall be expressed both in actual numbers and as a percentage of patient care staff and shall be broken down in terms of the total patient care staff, each unit, and each shift.
4. (iv) Incidence of adverse patient care, including incidents such as medication errors, patient injury, decubitus ulcers, nosocomial infections, and nosocomial urinary tract infections.
5. (v) Methods used for determining and adjusting staffing levels and patient care needs and the facility's compliance with these methods.
6. (vi) Data regarding complaints filed with any state or federal regulatory agency, or an accrediting agency, and data regarding investigations and findings as a result of those complaints, degree of compliance with acceptable standards, and the findings of scheduled inspection visits.
7. (b) Such information shall be provided to the commissioner of any state agency responsible for licensing or accrediting the facility, or responsible for overseeing the delivery of services either directly or indirectly, to any employee of a general hospital or the employee's collective bargaining agent, if any, and to any member of the public who requests such information directly from the facility. Written statements containing such information shall state the source and date thereof.
8. (c) The commissioner shall make regulations to provide a uniform format or form for complying with the reporting requirements of subparagraphs (i), (ii) and (iii) of paragraph (a) of this subdivision, allowing patients and the public to clearly understand and compare staffing patterns and actual levels of staffing across facilities. Such uniform format or form shall allow facilities to include a description of additional resources available to support unit level patient care and a description of the general hospital. The information required by subparagraphs (i), (ii) and (iii) of paragraph (a) of this subdivision, reported in a manner determined by the commissioner, shall be filed with the department electronically on a quarterly basis and shall be available to the public on the department's website. The regulations shall take effect no later than December thirty-first, two thousand twenty-two. Information required to be provided pursuant to subparagraphs (i), (ii) and (iii) of paragraph (a) of this subdivision shall be made available to the public no later than July first, two thousand twenty-three.