BILL NUMBER: AB 394	CHAPTERED
	BILL TEXT

	CHAPTER   945
	FILED WITH SECRETARY OF STATE   OCTOBER 10, 1999
	APPROVED BY GOVERNOR   OCTOBER 10, 1999
	PASSED THE ASSEMBLY   SEPTEMBER 9, 1999
	PASSED THE SENATE   SEPTEMBER 8, 1999
	AMENDED IN SENATE   SEPTEMBER 3, 1999
	AMENDED IN SENATE   AUGUST 16, 1999
	AMENDED IN SENATE   JULY 6, 1999
	AMENDED IN SENATE   JUNE 23, 1999
	AMENDED IN ASSEMBLY   JUNE 1, 1999

INTRODUCED BY   Assembly Member Kuehl
   (Coauthors:  Assembly Members Calderon, Dutra, Gallegos, and
Villaraigosa)
   (Coauthors:  Senators Burton, Escutia, and Perata)

                        FEBRUARY 11, 1999

   An act to add Section 2725.3 to the Business and Professions Code,
and to add Section 1276.4 to the Health and Safety Code, relating to
health care.



	LEGISLATIVE COUNSEL'S DIGEST


   AB 394, Kuehl.  Health facilities:  nursing staff.
   Existing law provides for the licensing, registration, and
regulation of nurses, and sets forth the scope of practice.
   This bill would prohibit a general acute care hospital, an acute
psychiatric hospital, and a special hospital, as defined, from
assigning an unlicensed person to perform nursing functions in lieu
of a registered nurse, or from allowing unlicensed personnel under
the direct clinical supervision of a registered nurse to perform
certain functions.
   Existing law prohibits operation of a health facility, as defined,
without a license issued by the State Department of Health Services
and provides for the issuance of licenses and for the regulation of
health facilities and sets forth the services to be provided therein.
  Willful or repeated violation of these provisions is a crime.
   This bill would require the department, with regard to general
acute care hospitals, acute psychiatric hospitals, and special
hospitals, to adopt regulations that establish certain minimum
nurse-to-patient ratios, and would require these health facilities to
adopt written policies and procedures for training and orientation
of nursing staff.  This bill would authorize the department to take
into consideration the unique nature of the University of California
teaching hospitals as educational institutions when establishing the
ratios, in accordance with certain requirements.  This bill would
also require a county hospital in Los Angeles County to be subject to
a phase-in process developed in conjunction with the department.
   By changing the definition of an existing crime this bill would
impose a state-mandated local program.
  The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state.  Statutory provisions establish procedures for making that
reimbursement.
   This bill would provide that no reimbursement is required by this
act for a specified reason.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:


  SECTION 1.  The Legislature finds and declares all of the
following:
   (a) Health care services are becoming complex and it is
increasingly difficult for patients to access integrated services.
   (b) Quality of patient care is jeopardized because of staffing
changes implemented in response to managed care.
   (c) To ensure the adequate protection of patients in acute care
settings, it is essential that qualified registered nurses and other
licensed nurses be accessible and available to meet the needs of
patients.
   (d) The basic principles of staffing in the acute care setting
should be based on the patient's care needs, the severity of
condition, services needed, and the complexity surrounding those
services.
  SEC. 2.  Section 2725.3 is added to the Business and Professions
Code, to read:
   2725.3.  (a) A health facility licensed pursuant to subdivision
(a), (b), or (f), of Section 1250 of the Health and Safety Code shall
not assign unlicensed personnel to perform nursing functions in lieu
of a registered nurse and may not allow unlicensed personnel to
perform functions under the direct clinical supervision of a
registered nurse that require a substantial amount of scientific
knowledge and technical skills, including, but not limited to, any of
the following:
   (1) Administration of medication.
   (2) Venipuncture or intravenous therapy.
   (3) Parenteral or tube feedings.
   (4) Invasive procedures including inserting nasogastric tubes,
inserting catheters, or tracheal suctioning.
   (5) Assessment of patient condition.
   (6) Educating patients and their families concerning the patient's
health care problems, including postdischarge care.
   (7) Moderate complexity laboratory tests.
   (b) This section shall not preclude any person from performing any
act or function that he or she is authorized to perform pursuant to
Division 2 (commencing with Section 500) or pursuant to existing
statute or regulation as of July 1, 1999.
  SEC. 3.  Section 1276.4 is added to the Health and Safety Code, to
read:
   1276.4.  (a) By January 1, 2001, the State Department of Health
Services shall adopt regulations that establish minimum, specific,
and numerical licensed nurse-to-patient ratios by licensed nurse
classification and by hospital unit for all health facilities
licensed pursuant to subdivision (a), (b), or (f) of Section 1250.
The department shall adopt these regulations in accordance with the
department's licensing and certification regulations as stated in
Sections 70053.2, 70215, and 70217 of Title 22 of the California Code
of Regulations, and the professional and vocational regulations in
Section 1443.5 of Title 16 of the California Code of Regulations.
The department shall review these regulations five years after
adoption and shall report to the Legislature regarding any proposed
changes.  Flexibility shall be considered by the department for rural
general acute care hospitals in response to their special needs.  As
used in this subdivision, "hospital unit" means a critical care
unit, burn unit, labor and delivery room, postanesthesia service
area, emergency department, operating room, pediatric unit,
step-down/intermediate care unit, specialty care unit, telemetry
unit, general medical care unit, subacute care unit, and transitional
inpatient care unit.  The regulation addressing the emergency
department shall distinguish between regularly scheduled core staff
licensed nurses and additional licensed nurses required to care for
critical care patients in the emergency department.
   (b) These ratios shall constitute the minimum number of registered
and licensed nurses that shall be allocated.  Additional staff shall
be assigned in accordance with a documented patient classification
system for determining nursing care requirements, including the
severity of the illness, the need for specialized equipment and
technology, the complexity of clinical judgment needed to design,
implement, and evaluate the patient care plan and the ability for
self-care, and the licensure of the personnel required for care.
   (c) "Critical care unit" as used in this section means a unit that
is established to safeguard and protect patients whose severity of
medical conditions requires continuous monitoring, and complex
intervention by licensed nurses.
   (d) All health facilities licensed under subdivision (a), (b), or
(f) of Section 1250 shall adopt written policies and procedures for
training and orientation of nursing staff.
   (e) No registered nurse shall be assigned to a nursing unit or
clinical area unless that nurse 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.
   (f) The written policies and procedures for orientation of nursing
staff shall require that all temporary personnel shall receive
orientation and be subject to competency validation consistent with
Sections 70016.1 and 70214 of Title 22 of the California Code of
Regulations.
   (g) Requests for waivers to this section that do not jeopardize
the health, safety, and well-being of patients affected and that are
needed for increased operational efficiency may be granted by the
state department to rural general acute care hospitals meeting the
criteria set forth in Section 70059.1 of Title 22 of the California
Code of Regulations.
   (h) In case of conflict between this section and any provision or
regulation defining the scope of nursing practice, the scope of
practice provisions shall control.
   (i) The regulations adopted by the department shall augment and
not replace existing nurse-to-patient ratios that exist in regulation
or law for the intensive care units, the neonatal intensive care
units, or the operating room.
   (j) The regulations adopted by the department shall not replace
existing licensed staff-to-patient ratios for hospitals operated by
the State Department of Mental Health.
   (k) The regulations adopted by the department for health
facilities licensed under subdivision (b) of Section 1250 that are
not operated by the State Department of Mental Health shall take into
account the special needs of the patients served in the psychiatric
units.
   (l) The department may take into consideration the unique nature
of the University of California teaching hospitals as educational
institutions when establishing licensed nurse-to-patient ratios.  The
department shall coordinate with the Board of Registered Nursing to
ensure that staffing ratios are consistent with the Board of
Registered Nursing approved nursing education requirements.  This
includes nursing clinical experience incidental to a work-study
program rendered in a University of California clinical facility
approved by the Board of Registered Nursing provided there will be
sufficient direct care registered nurse preceptors available to
ensure safe patient care.
   (m) A county hospital in a county of the first class, as defined
in Section 28022 of the Government Code, shall be subject to a
phase-in process developed in conjunction with the department.  This
phase-in process shall be completed within one year of the adoption
of the regulations that implement this section.
  SEC. 4.  No reimbursement is required by this act pursuant to
Section 6 of Article XIIIB of the California Constitution because the
only costs that may be incurred by a local agency or school district
will be incurred because this act creates a new crime or infraction,
eliminates a crime or infraction, or changes the penalty for a crime
or infraction, within the meaning of Section 17556 of the Government
Code, or changes the definition of a crime within the meaning of
Section 6 of Article XIIIB of the California Constitution.