(a) For purposes of this section: (1) “Department” means the Department of Public Health; (2) “Hospital” means an establishment for the lodging, care and treatment of persons suffering from disease or other abnormal physical or mental conditions and includes inpatient psychiatric services in general hospitals; (3) “Assistive personnel” means personnel who are not licensed by the Department of Public Health and who engage in specifically delegated patient care activities; and (4) “Direct care registered nurse” means a registered nurse licensed pursuant to chapter 378 whose primary responsibility is to provide direct patient care. (b) Each hospital licensed by the department pursuant to chapter 368v shall report, not later than January first and July first annually, to the department on a prospective nurse staffing plan with a written certification that the nurse staffing plan developed pursuant to subsections (d) and (e) of this section is sufficient to provide adequate and appropriate delivery of health care services to patients in the ensuing period of licensure. Such plan shall promote a collaborative practice in the hospital that enhances patient care and the level of services provided by nurses and other members of the hospital's patient care team. (c) (1) Each hospital shall establish a dedicated hospital staffing committee to assist in the preparation of the nurse staffing plan required pursuant to subsection (b) of this section. Direct care registered nurses employed by the hospital shall account for not less than fifty per cent and an odd number of members of the membership of each hospital's staffing committee. The total number of direct care registered nurses shall be one more than the total number of nondirect care registered nurses of such committee. Each hospital's staffing committee shall include broad-based representation across hospital services. When registered nurses employed by the hospital are members of a collective bargaining unit, (A) the collective bargaining unit shall select the direct care registered nurse members that comprise not less than fifty per cent of the total number of members of such committee, provided such selection is not prohibited conduct under the National Labor Relations Act, 29 USC 151, et seq., as amended from time to time, 5 USC 71, as amended from time to time, or the State Employee Relations Act, section 5-270 , et seq., as amended from time to time, and (B) a representative of the collective bargaining unit shall provide the hospital with a list of multiple names of direct care registered nurses from which hospital management shall select the one additional direct care registered nurse member beyond the fifty per cent of the direct care registered nurse members. Direct care registered nurses who are not members of a collective bargaining unit shall be selected for the committee through a process determined by the direct care registered nurses of the hospital. The hospital staffing committee that was in existence prior to October 1, 2023, shall solicit feedback from all direct care registered nurses employed by the hospital regarding what such process should entail. The direct care registered nurses who are members of such existing hospital staffing committee shall decide, by majority vote, the parameters of such process. Hospital management shall select the remaining members of such committee. (2) Each hospital shall pay each employee who serves on the hospital staffing committee such employee's regular rate of pay, including differentials, for participation on the committee and consider, to the extent possible by the hospital, the time such employee serves on the committee as part of such employee's regularly scheduled work week. Each hospital shall ensure that direct care registered nurses have coverage to attend hospital staffing committee meetings. (3) Each hospital staffing committee shall include two cochairpersons who have direct patient care experience, one of whom is a direct care registered nurse at the hospital who shall be elected by members of the committee who are direct care registered nurses, and one of whom shall be elected by members of the committee who are not direct care registered nurses. The committee shall take minutes of every meeting, make such minutes available to any member of the hospital staff upon request and submit such minutes to the Department of Public Health when requested by the department. A majority of the members of the staffing committee shall constitute a quorum for the transaction of staffing committee business. A decision made by the hospital staffing committee shall be made by a vote of a majority of the members present at the meeting. If a quorum of members present at a meeting comprises an equal number of members who are direct care registered nurses and members who are not direct care registered nurses, a sufficient number of members who are not direct care registered nurses shall abstain from voting to allow a majority of the voting members to consist of direct care registered nurses. (4) Each hospital shall notify each nurse on the nurse's date of hire, and annually thereafter, about the hospital staffing committee, including, but not limited to, the purpose of the committee, the criteria and process for becoming a member of the committee, the hospital's process for internal review of the nurse staffing plan and the hospital's mechanism for obtaining input from direct care staff, including direct care registered nurses and other members of the hospital's patient care team, in the development of the nurse staffing plan. (d) Each hospital staffing committee shall develop the nurse staffing plan for the hospital. In developing such plan, the committee shall evaluate the most recent research regarding patient outcomes, share with hospital staff the procedures for communicating concerns to the committee regarding such plan and staffing assignments and review all reports regarding any such concerns and any objections or refusals by a registered nurse to participate in a staffing assignment made pursuant to subsection (h) of this section that were communicated to the committee. Each hospital shall implement such plan. Such plan shall: (1) Include the minimum professional skill mix for each patient care unit in the hospital, including, but not limited to, inpatient services, critical care and the emergency department; (2) identify the hospital's employment practices concerning the use of temporary and traveling nurses; (3) set forth the level of administrative staffing in each patient care unit of the hospital that ensures direct care staff are not utilized for administrative functions; (4) set forth the hospital's process for internal review of the nurse staffing plan; and (5) include the hospital's mechanism of obtaining input from direct care staff, including nurses and other members of the hospital's patient care team, in the development of the nurse staffing plan. In addition to the information described in subdivisions (1) to (5), inclusive, of this subsection, nurse staffing plans developed and implemented after January 1, 2016, shall include: (A) The number of registered nurses providing direct patient care and the ratio of patients to such registered nurses by patient care unit; (B) the number of licensed practical nurses providing direct patient care and the ratio of patients to such licensed practical nurses, by patient care unit; (C) the number of assistive personnel providing direct patient care and the ratio of patients to such assistive personnel, by patient care unit; (D) the method used by the hospital to determine and adjust direct patient care staffing levels; and (E) a description of assistive personnel on each patient care unit. In addition to the information described in subdivisions (1) to (5), inclusive, of this subsection and subparagraphs (A) to (E), inclusive, of this subdivision, nurse staffing plans developed and implemented after January 1, 2017, shall include: (i) A description of any differences between the staffing levels described in the staffing plan and actual staffing levels for each patient care unit; and (ii) any actions the hospital intends to take to address such differences or adjust staffing levels in future staffing plans. (e) On and after January 1, 2024, in addition to the information required pursuant to subsection (d) of this section, each nurse staffing plan shall include: (1) Information about any objections to or refusals to comply with the nurse staffing plan by hospital staff that were communicated to the hospital staffing committee; (2) Measurements of and evidence to support successful implementation of the nurse staffing plan; (3) Retention, turnover and recruitment metrics for direct care registered nursing staff, including, but not limited to, the turnover rate per hospital unit during the preceding twelve months and the average years of experience of permanent direct care registered nursing staff per unit; (4) The number of instances since the last nurse staffing plan was submitted when the hospital was not in compliance with such plan, including, but not limited to, the nurse staffing ratios set forth in such plan, and a description of how and why such plan was not complied with and plans to avoid future noncompliance with such plan; and (5) Certification that the hospital and its hospital staffing committee are meeting the requirements set forth in this section and a description of how each requirement is being met. (f) Each hospital shall post the nurse staffing plan developed and adopted pursuant to subsections (d) and (e), inclusive, of this section on each patient care unit in a conspicuous location visible and accessible to staff, patients and members of the public. Each hospital shall maintain accurate records, for not less than the preceding three years, of the ratios of patients to direct care registered nurses and patients to assistive personnel providing patient care in each direct care unit for each shift. Such records shall include the number of (1) patients in each unit on each shift, (2) direct care registered nurses assigned to each patient in each unit on each shift, and (3) assistive personnel providing patient care assigned to each patient in each unit on each shift. Each hospital shall make such records available, upon request, to the Department of Public Health, the staff of the hospital, any collective bargaining unit representing such staff, the patients of the hospital and members of the general public. (g) No hospital shall require a registered nurse to undertake any patient care task that is beyond the scope of the nurse's license. (h) A registered nurse may object to or refuse to participate in any activity, policy, practice or task assigned by a hospital if the registered nurse is not competently able based on education, training or experience to participate in the activity, policy, practice or task without compromising the safety of a specific patient. If a registered nurse objects or refuses to participate, the nurse shall immediately contact a supervisor for assistance or to allow the hospital to find a suitable replacement. Not later than twelve hours after objecting or refusing to participate, the registered nurse shall submit a form, developed by the hospital and approved by the Department of Public Health, that includes the following: (1) A detailed statement of the reasons that the nurse objects or refuses to participate in the activity, policy, practice or task; (2) a description of how performing the activity, policy, practice or task would have compromised patient safety; and (3) the ways in which the activity, policy, practice or task was not consistent with the nurse's education, training, experience or job description. A hospital shall review and analyze each form submitted pursuant to this subsection through one or more of the hospital's committees or functions, including, but not limited to, the quality assessment and performance improvement program, risk management or patient safety, and make adjustments to nurse staffing assignments if necessary to improve patient safety. Each hospital shall provide the Department of Public Health with confidential access to the forms submitted to the hospital pursuant to this subsection upon request. (i) If a registered nurse reasonably believes his or her participation in an activity, policy, practice or task would violate a provision of a nurse staffing plan or policy approved by the hospital's nurse staffing committee, the nurse may file a complaint with the nurse staffing committee on a form developed by the hospital and approved by the Department of Public Health. The hospital and its nurse staffing committee shall analyze the complaint and provide the Department of Public Health with an analysis of actions taken in response to such complaint. The department shall submit all complaint forms provided to it pursuant to this subsection with its biannual report required pursuant to subsection (n) of this section. (j) No hospital shall discharge, retaliate against, discriminate against or take any other adverse action against a registered nurse or any aspect of the registered nurse's employment, including, but not limited to, discharge, promotion, reduction in compensation or changes to terms, conditions or privileges of employment, as a result of such nurse taking any of the actions described in this section, participation by the registered nurse in a hospital staffing committee or raising of concerns by the registered nurse regarding unsafe staffing or workplace violence, racism or bullying. (k) Nothing in this section shall be construed to allow a nurse to abandon a patient or refuse to perform patient care activities (1) during an ongoing surgical procedure until such procedure is completed; (2) in a critical care unit, labor and delivery or emergency department until such nurse is relieved by another nurse; (3) in the case of a public health emergency; (4) in the case of an institutional emergency; or (5) in any instance where inaction or abandonment by the nurse would jeopardize patient safety. (l) Nothing in this section shall prohibit a hospital, the Department of Public Health or the State Board of Examiners for Nursing from requiring a nurse to obtain additional training or continuing education consistent with the nurse's assigned roles and job description. (m) Not later than January 1, 2016, and annually thereafter, the Commissioner of Public Health shall report, in accordance with the provisions of section 11-4a , to the joint standing committee of the General Assembly having cognizance of matters relating to public health concerning hospital compliance with reporting requirements under this section and recommendations concerning any additional reporting requirements. (n) Not later than October 1, 2024, and biannually thereafter, a hospital shall report to the Department of Public Health, in a form and manner prescribed by the Commissioner of Public Health, whether it has been in compliance, for the previous six months, with at least eighty per cent of the nurse staffing assignments as required by any component outlined in the nurse staffing plan developed pursuant to subsections (d) and (e) of this section. (o) For a failure by a hospital to (1) establish or maintain a hospital staffing committee pursuant to subsection (c) of this section, (2) submit the report required by subsection (n) of this section to the Department of Public Health, (3) post the staffing plan pursuant to subsection (f) of this section, or (4) comply with at least eighty per cent of the nurse staffing assignments set forth in the nurse staffing plan, the Commissioner of Public Health shall issue an order that: (A) Requires the hospital to submit a corrective action plan to correct such noncompliance and implement such plan unless disapproved by the department not later than twenty business days after its submission; and (B) (i) imposes a civil penalty of three thousand five hundred dollars for the first violation, or (ii) imposes a civil penalty of five thousand dollars for each subsequent violation. (p) (1) A hospital shall, not later than five business days after receipt of an order pursuant to subsection (o) of this section, submit a request in writing to the Department of Public Health for a hearing to contest the order. If the hospital fails to submit such a request not later than five business days after such receipt, the order shall be deemed a final order of the department, effective upon the expiration of such five business days. After receipt of a timely request for a hearing, the department shall set the matter down for a hearing as a contested case in accordance with the provisions of chapter 54. (2) Each hospital shall pay any civil penalties imposed pursuant to subsection (o) of this section not later than fifteen days after the final date by which an appeal may be taken as provided in section 4-183 or, if an appeal is taken, not later than fifteen days after the final judgment on such appeal. If such penalties or the expenses of an audit ordered under subsection (q) of this section are not paid by the hospital, the Commissioner of Public Health shall notify the Commissioner of Social Services who shall be authorized to immediately withhold from the hospital's next medical assistance payment, an amount equal to the amount of the civil penalty and audit expenses. (q) The Commissioner of Public Health may order an audit of the nurse staffing assignments of each hospital to determine compliance with the nurse staffing assignments for each hospital unit set forth in the nurse staffing plan developed pursuant to subsections (d) and (e) of this section. Such audit may include an assessment of the hospital's compliance with the requirements of this section for the content of such plan, accuracy of reports submitted to the department and the membership of the hospital staffing committee. In determining whether to order an audit, the commissioner shall consider whether there has been consistent noncompliance by the hospital with the nurse staffing plan, fear of false reporting by the hospital or any other health care quality safety concerns. The hospital that is subject to the audit shall pay the cost of the audit. The audit shall not affect the conduct by the hospital of peer review as defined in section 19a-17b .