Section 255.150  Staffing Levels

a)         The number of registered professional nurses, licensed practical nurses, and other nursing personnel assigned to each patient care unit shall be consistent with the types of nursing care needed by the patients and the capabilities of the staff.  Patients on each unit shall be evaluated near the end of each change of shift by criteria developed by the nursing service.  There shall be staffing schedules reflecting actual nursing personnel required for the hospital and for each patient unit.  Staffing patterns shall reflect consideration of nursing goals, standards of nursing practice, and the needs of the patients.  (Section 15(a) of the Act)

b)         Current nursing staff schedules shall be available upon request at each patient care unit. Each schedule shall list the daily assigned nursing personnel and average daily census for the unit. (Section 15(b) of the Act)  The schedules shall be provided to the public for inspection in accordance with subsection (h) of this Section by providing a hard copy of the schedule, which may be in the form of scheduling logs, schedule postings, print outs of electronic screens, and sign-up sheets, but shall not contain information identifying a patient, employee, licensed nurse, or other licensed professional.  Hospitals may also make schedules available by other means in addition to the hard copy format.  The average daily census that must be referenced on each prospective schedule should reflect the unit's average daily census from the prior fiscal year data.

c)         Hospitals and the Department shall notify the public of the right to access nurse staffing information and provide information for obtaining nurse staffing information.  The Department shall include this information on its web site.  Hospitals shall provide this information through one or more communication channels, for example, disseminate patient education materials or include information on obtaining nurse staffing information on the hospital web site.

d)         The actual nurse staffing assignment roster for each patient care unit shall be available upon request at the patient care unit for the effective date of that roster.  (Section 15(b) of the Act)  The actual nurse staffing assignment rosters will be provided to the public for inspection in accordance with subsection (h) of this Section by providing a hard copy of the roster.  Hospitals may also make rosters available by other means in addition to the hard copy format. Hospitals shall have the ability to satisfy requests for the current rosters or schedules by providing the information at each unit. Requests for non-current rosters or schedules may be satisfied by directing the requestor from the unit to a hospital location where the information is kept for the purpose of providing information to the public.

e)         All records required under this Section, including anticipated staffing schedules and the methods to determine and adjust staffing levels, shall be made available to the public upon request.  (Section 15(c) of the Act)  Methods for determining and adjusting staffing levels may be contained in hospital policies and procedures, administrative regulations, staff plans, accreditation standards, collective bargaining agreements and commercially developed patient acuity tools and protocols.  Nothing in this Part requires hospitals to adopt any particular staffing level methodology. This information shall be made available to the public for inspection as provided in subsection (h) of this Section at a central location or at specific patient care units.

f)         All records required under Section 15 of the Act shall be maintained by the facility for no less than 5 years. (Section 15(d) of the Act)

g)         Requests for information under this Section may be communicated to the hospital by any reasonable means, including, but not limited to, written, telephone or on-site inquiries.  Hospitals shall be prepared to receive requests and respond accordingly as outlined in subsection (h) of this Section.  Hospitals may require these requests to be made in writing in order to document the specifics of each request.  If individual hospitals choose to require requests to be made in writing, the hospitals shall then develop a simple form that will fulfill this writing requirement.

h)         Copies of schedules, rosters, or other nurse staffing records made available to the public must not contain information identifying a patient, employee, licensed nurse, or other licensed professional.  Information required to be made available to the public under this Section shall be made available as follows:

1)         For requests related to an individual person's pending or current inpatient hospital stay:

A)        The current nursing staff schedule may be requested at any time and shall be made available within two hours after the request.

B)        The current actual nurse staffing assignment roster may be requested at any time and shall be made available within 2 hours after the request during normal business hours during the week and within 4 hours on weekends and evening hours.

2)         For requests unrelated to an individual person's pending or current inpatient hospital stay:

A)        Other nurse staffing records, including the methods to determine and adjust staffing levels, historical records, and records in off-site storage, may be requested at times specified by the hospital, but at least Monday through Friday from 9:00 a.m. to 5:00 p.m.  The hospital shall comply with a written request for these records within seven business days after its receipt.  These records shall be made available at a central location on hospital grounds.

B)        If the hospital is unable to provide the requested records in the time frame required by subsection (h)(2)(A) of this Section, the hospital shall notify the individual making the written request within the time limits specified in subsection (h)(2)(A) of this Section of the reason for the delay and the date by which the requested records shall be made available.