Bill Text: PA HB147 | 2009-2010 | Regular Session | Introduced


Bill Title: Further providing for purposes, for definitions, for powers of the Department of Health, for administration and for licensure; providing for compliance with staffing plans and recordkeeping, for work assignment policies and for public disclosure of staffing requirements; further providing for license standards, reliance on accrediting agencies and Federal Government, for medical assistance payments and for civil penalties; and providing for private cause of action and for grants and loan programs for nurse recruitment.

Spectrum: Moderate Partisan Bill (Democrat 47-9)

Status: (Introduced - Dead) 2009-01-30 - Referred to HEALTH AND HUMAN SERVICES [HB147 Detail]

Download: Pennsylvania-2009-HB147-Introduced.html

  

 

    

PRINTER'S NO.  143

  

THE GENERAL ASSEMBLY OF PENNSYLVANIA

  

HOUSE BILL

 

No.

147

Session of

2009

  

  

INTRODUCED BY SOLOBAY, BELFANTI, BEYER, BISHOP, BRENNAN, CALTAGIRONE, COHEN, CONKLIN, CREIGHTON, DeLUCA, GOODMAN, GRUCELA, HARKINS, MAHONEY, McCALL, McILVAINE SMITH, MELIO, MICOZZIE, READSHAW, SIPTROTH AND WHITE, JANUARY 30, 2009

  

  

REFERRED TO COMMITTEE ON HEALTH AND HUMAN SERVICES, JANUARY 30, 2009  

  

  

  

AN ACT

  

1

Amending the act of July 19, 1979 (P.L.130, No.48), entitled "An

2

act relating to health care; prescribing the powers and

3

duties of the Department of Health; establishing and

4

providing the powers and duties of the State Health

5

Coordinating Council, health systems agencies and Health Care

6

Policy Board in the Department of Health, and State Health

7

Facility Hearing Board in the Department of Justice;

8

providing for certification of need of health care providers

9

and prescribing penalties," further providing for purposes,

10

for definitions, for powers of the Department of Health, for

11

administration and for licensure; providing for compliance

12

with staffing plans and recordkeeping, for work assignment

13

policies and for public disclosure of staffing requirements;

14

further providing for license standards, reliance on

15

accrediting agencies and Federal Government, for medical

16

assistance payments and for civil penalties; and providing

17

for private cause of action and for grants and loan programs

18

for nurse recruitment.

19

The General Assembly of the Commonwealth of Pennsylvania

20

hereby enacts as follows:

21

Section 1.  Section 102 of the act of July 19, 1979 (P.L.130,

22

No.48), known as the Health Care Facilities Act, is amended to

23

read:

24

Section 102.  Purposes.

 


1

The General Assembly finds [that] as follows:

2

(1)  That the health and welfare of Pennsylvania citizens

3

will be enhanced by the orderly and economical distribution

4

of health care resources to prevent needless duplication of

5

services. Such distribution of resources will be further by

6

governmental involvement to coordinate the health care

7

system. Such a system will enhance the public health and

8

welfare by making the delivery system responsive and adequate

9

to the needs of its citizens, and assuring that new health

10

care services and facilities are efficiently and effectively

11

used; that health care services and facilities continue to

12

meet high quality standards; and, that all citizens receive

13

humane, courteous and dignified treatment. In developing such

14

a coordinated health care system, it is the policy of the

15

Commonwealth to foster responsible private operation and

16

ownership of health care facilities, to encourage innovation

17

and continuous development of improved methods of health care

18

and to aid efficient and effective planning using local

19

health systems agencies. It is the intent of the General

20

Assembly that the Department of Health foster a sound health

21

care system which provides for quality care at appropriate

22

health care facilities throughout the Commonwealth.

23

(2)  That a substantial interest exists in assuring that

24

delivery of health care services to patients in health care

25

facilities located within this Commonwealth is adequate and

26

safe and that health care facilities retain sufficient

27

nursing staff so as to promote optimal health care outcomes.

28

Inadequate hospital staffing results in dangerous medical

29

errors and patient infections. Registered nurses constitute

30

the highest percentage of direct health care staff in acute

- 2 -

 


1

care facilities and have a central role in health care

2

delivery. To ensure the adequate protection and care for

3

patients in health care facilities it is essential that

4

qualified registered nurses be accessible and available to

5

meet the nursing needs of patients. Inadequate and poorly

6

monitored nurse staffing practices which result in having too

7

few registered nurses providing care jeopardize delivery of

8

quality health care services and adversely impact the health

9

of patients who enter hospitals and outpatient emergency and

10

surgical centers. The basic principles of staffing in health

11

care facilities should be focused on patient health care

12

needs and based on consideration of patient acuity levels and

13

services that need to be provided to ensure optimal outcomes.

14

While the focus of this act is on registered nurses who are

15

principal caregivers, safe staffing practices recognize the

16

importance of all health care workers in providing quality

17

patient care. The setting of staffing standards for registered

18

nurses is not to be interpreted as justifying the understaffing

19

of other critical health care workers, including licensed

20

practical nurses, social workers and unlicensed assistive

21

personnel. Indeed, the availability of these other health care

22

workers enables registered nurses to focus on the nursing care

23

functions that only registered nurses, by law, are permitted to

24

perform and thereby helps to ensure adequate staffing levels.

25

Establishing staffing standards for registered nurses in acute

26

care facilities ensures that health care facilities throughout

27

this Commonwealth operate in a manner that guarantees the public

28

safety and the delivery of quality health care services. In

29

order to meet these standards incentives must be created to

30

increase the number of registered nurses within this

- 3 -

 


1

Commonwealth.

2

Section 2.  Section 103 of the act is amended by adding

3

definitions to read:

4

Section 103.  Definitions.

5

The following words and phrases when used in this act shall

6

have, unless the context clearly indicates otherwise, the

7

meanings given to them in this section:

8

* * *

9

"Acuity system."  An established measurement instrument that:

10

(1)  Predicts nursing care requirements for individual

11

patients based on severity of patient illness, need for

12

specialized equipment and technology, intensity of nursing

13

interventions required and the complexity of clinical nursing

14

judgment needed to design, implement and evaluate the

15

patient's nursing care plan.

16

(2)  Details the amount of nursing care needed, both in

17

number of direct-care nurses and in skill mix of nursing

18

personnel required on a daily basis for each patient in a

19

nursing department or unit.

20

(3)  Is stated in terms that readily can be used and

21

understood by direct-care nurses. The acuity system shall

22

take into consideration the patient care services provided

23

not only by registered nurses but also by licensed practical

24

nurses and other health care personnel.

25

"Assessment tool."  A measurement system that compares the

26

staffing level in each nursing department or unit against actual

27

patient nursing care requirements in order to review the

28

accuracy of an acuity system.

29

* * *

30

"Direct-care nurse."  A registered nurse who has direct

- 4 -

 


1

responsibility to oversee or directly carry out medical

2

regimens, nursing or other bedside care for one or more

3

patients.

4

"Documented staffing plan."  A detailed written plan setting

5

forth the minimum number and classification of direct-care

6

nurses required in each nursing department or unit in the health

7

facility for a given year, based on reasonable projections

8

derived from the patient census and average acuity level within

9

each department or unit during the prior year, the department or

10

unit size and geography, the nature of services provided and any

11

foreseeable changes in department or unit size or function

12

during the current year.

13

"Extended care facility."  A home health care agency, a

14

hospice or a long-term care nursing facility.

15

* * *

16

"Nurse" or "registered nurse."  An individual licensed to

17

practice professional nursing under the act of May 22, 1951

18

(P.L.317, No.69), known as "The Professional Nursing Law."

19

"Nursing care."  Care that falls within the scope of practice

20

as prescribed by State law or otherwise encompassed within

21

recognized professional standards of nursing practice, including

22

assessment, nursing diagnosis, planning, intervention,

23

evaluation and patient advocacy.

24

* * *

25

"Staffing level."  The actual numerical nurse-to-patient

26

ratio within a nursing department or unit.

27

* * *

28

"Unit."  A patient care component within a facility as

29

defined by the Department of Health.

30

Section 3.  Section 803 of the act, added July 12, 1980 (P.L.

- 5 -

 


1

655, No.136), is amended to read:

2

Section 803.  Powers of the Department of Health.

3

The Department of Health shall have the power and its duty

4

shall be:

5

(1)  to promulgate, after consultation with the policy

6

board, the rules and regulations necessary to carry out the

7

purposes and provisions of this chapter[; and], including

8

regulations defining terms, setting forth direct-care nurse-

9

to-patient ratios and prescribing the process for approving

10

acuity systems;

11

(2)  to assure that the provisions of this chapter and

12

all rules and regulations promulgated under this chapter are

13

enforced[.]; and

14

(3)  to promulgate, within six months of the effective

15

date of this paragraph, regulations providing for an

16

accessible and confidential system to report the failure to

17

comply with requirements of this chapter and public access to

18

information regarding reports of inspections, results,

19

deficiencies and corrections under this chapter.

20

Section 4.  Sections 804 and 806 of the act are amended by

21

adding subsections to read:

22

Section 804.  Administration.

23

* * *

24

(e)  Approval of acuity system.--The department shall adopt

25

regulations prescribing the method by which it will approve a

26

facility's acuity system. The regulations may include a system

27

for class approval of acuity systems.

28

Section 806.  Licensure.

29

* * *

30

(h)  Staffing requirements.--Each health care facility, other

- 6 -

 


1

than an extended care facility, licensed pursuant to this act

2

shall ensure that it is staffed in a manner that provides

3

sufficient, appropriately qualified direct-care nurses in each

4

department or unit within the facility in order to meet the

5

individualized care needs of its patients and to meet all of the

6

following requirements:

7

(1)  As a condition of licensing, each facility annually

8

shall submit to the department a documented staffing plan

9

together with a written certification that the staffing plan

10

is sufficient to provide adequate and appropriate delivery of

11

health care services to patients for the ensuing year and

12

does all of the following:

13

(i)  meets the minimum requirements of paragraph (2);

14

(ii)  meets any additional requirements of other laws

15

or regulations;

16

(iii)  employs and identifies an approved acuity

17

system for addressing fluctuations in actual patient

18

acuity levels and nursing care requirements requiring

19

increased staffing levels above the minimums set forth in

20

the plan;

21

(iv)  factors in other unit or department activity

22

such as discharges, transfers and admissions,

23

administrative and support tasks that are expected to be

24

done by direct-care nurses in addition to direct nursing

25

care;

26

(v)  factors in the staffing level of and services

27

provided by other health care personnel in meeting

28

patient care needs, except that the staffing plan may not

29

incorporate or assume that nursing care functions

30

required by licensing law or regulations or accepted

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1

standards of practice to be performed by a registered

2

nurse are to be performed by other personnel;

3

(vi)  identifies the assessment tool used to validate

4

the acuity system relied on in the plan;

5

(vii)  identifies the system that will be used to

6

document actual staffing on a daily basis within each

7

department or unit;

8

(viii)  includes a written assessment of the accuracy

9

of the prior year's staffing plan in light of actual

10

staffing needs;

11

(ix)  identifies each nurse staff classification

12

referenced in the plan together with a statement setting

13

forth minimum qualifications for each classification; and

14

(x)  is produced in consultation with a majority of

15

the direct-care nurses within each department or unit or,

16

where applicable, with the recognized or certified

17

collective bargaining representative or representative of

18

the direct-care nurses.

19

(2)  The staffing plan must incorporate, at a minimum,

20

the following direct-care nurse-to-patient ratios:

21

(i)  One nurse to one patient: operating room and

22

trauma emergency units.

23

(ii)  One nurse to two patients: all critical care

24

areas including emergency critical care and all intensive

25

care units, labor and delivery units and postanesthesia

26

units.

27

(iii)  One nurse to three patients: antepartum,

28

emergency room, pediatrics, step-down and telemetry

29

units.

30

(iv)  One nurse to four patients: intermediate care

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1

nursery, and medical/surgical and acute care psychiatric

2

units.

3

(v)  One nurse to five patients: rehabilitation

4

units.

5

(vi)  One nurse to six patients: postpartum (three

6

couplets) and well-baby nursery units.

7

(vii)  For any units not listed above, including

8

psychiatric units in facilities other than acute care

9

hospitals, the direct-care nurse-to-patient ratio as

10

established by the department.

11

(3)  The ratios set forth in paragraph (2) shall

12

constitute the maximum number of patients that may be

13

assigned to each direct-care nurse in a unit during one

14

shift. A nurse, including a nurse administrator or

15

supervisor, who does not have principal responsibility as a

16

direct-care nurse for a specific patient shall not be

17

included in the calculation of the nurse-to-patient ratio.

18

(4)  Nothing shall preclude the department from

19

establishing and requiring a staffing plan to have higher

20

nurse-to-patient ratios than those set forth in paragraph

21

(2).

22

(5)  The staffing plan may not incorporate or assume that

23

nursing care functions required by licensing law or

24

regulations or accepted standards of practice to be performed

25

by a registered nurse are to be performed by other personnel.

26

Section 5.  The act is amended by adding sections to read:

27

Section 806.5.  Compliance with staffing plan and recordkeeping.

28

(a)  Plan.--As a condition of licensing, a health care

29

facility required to have a staffing plan under section 806(h)

30

shall at all times staff in accordance with its staffing plan

- 9 -

 


1

and the staffing standards set forth under section 806(h),

2

provided that nothing herein shall be deemed to preclude the

3

health care facility from implementing higher direct-care nurse-

4

to-patient staffing levels, nor shall the requirements set forth

5

be deemed to supersede or replace any higher requirements

6

otherwise mandated by law, regulation or contract.

7

(b)  Appropriate license required.--For purposes of

8

compliance with the minimum staffing requirements standards set

9

forth under section 806(h), no nurse shall be assigned, or

10

included in the count of assigned nursing staff in a nursing

11

department or unit or a clinical area within the health facility

12

unless that nurse has an appropriate license under the

13

applicable registered nurse law, received prior orientation in

14

that clinical area sufficient to provide competent nursing care

15

to the patients in that area, and has demonstrated current

16

competence in providing care in that area. Hospitals that

17

utilize temporary nursing agencies shall have and adhere to a

18

written procedure to orient and evaluate personnel from these

19

sources to ensure adequate orientation and competency prior to

20

inclusion in the nurse-to-patient ratio.

21

(c)  Daily records.--As a condition of licensure, each health

22

care facility required to have a staffing plan under section

23

806(h) shall maintain accurate daily records showing:

24

(1)  The number of patients admitted, released and

25

present in each nursing department or unit within the

26

facility.

27

(2)  The individual acuity level of each patient present

28

in each nursing department or unit within the facility.

29

(3)  The identity and duty hours of each direct-care

30

nurse in each nursing department or unit within the facility.

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1

(d)  Daily statistics.--As a condition of licensure, each

2

health care facility required to have a staffing plan under

3

section 806(h) shall maintain daily statistics, by nursing

4

department and unit, of mortality, morbidity, infection,

5

accident, injury and medical errors.

6

(e)  Records retention.--All records required to be kept

7

under this section shall be maintained for a period of seven

8

years.

9

(f)  Availability of records.--All records required to be

10

kept under this section shall be made available upon request to

11

the department and to the public, provided that information

12

released to the public shall comply with applicable patient

13

privacy laws and regulations.

14

Section 806.6.  Work assignment policy.

15

(a)  Written policy.--As a condition of licensure, each

16

health care facility other than an extended care facility shall

17

adopt, disseminate to direct-care nurses and comply with a

18

written policy that meets the requirements of this section,

19

detailing the circumstances under which a direct-care nurse may

20

refuse a work assignment.

21

(b)  Minimum conditions.--At a minimum, the work assignment

22

policy shall permit a direct-care nurse to refuse an assignment

23

for which:

24

(1)  The nurse is not prepared by education, training or

25

experience to safely fulfill the assignment without

26

compromising or jeopardizing patient safety, the nurse's

27

ability to meet foreseeable patient needs or the nurse's

28

license.

29

(2)  The assignment otherwise would violate requirements

30

under this act.

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1

(c)  Minimum procedures.--At a minimum, the work assignment

2

policy shall contain procedures for the following:

3

(1)  Reasonable requirements for prior notice to the

4

nurse's supervisor regarding the nurse's request and

5

supporting reasons for being relieved of the assignment or

6

continued duty.

7

(2)  Where feasible, an opportunity for the supervisor to

8

review the specific conditions supporting the nurse's

9

request, and to decide whether to remedy the conditions, to

10

relieve the nurse of the assignment or to deny the nurse's

11

request to be relieved of the assignment or continued duty.

12

(3)  A process that permits the nurse to exercise the

13

right to refuse the assignment or continued on-duty status

14

when the supervisor denies the request to be relieved if:

15

(i)  the supervisor rejects the request without

16

proposing a remedy or the proposed remedy would be

17

inadequate or untimely;

18

(ii)  the complaint and investigation process with a

19

regulatory agency would be untimely to address concern;

20

and

21

(iii)  the employee in good faith believes that the

22

assignment meets conditions justifying refusal.

23

(4)  A nurse who refuses an assignment pursuant to a work

24

assignment policy established in this section shall not be

25

deemed, for that reason, to have engaged in negligent or

26

incompetent action, patient abandonment or otherwise to have

27

violated applicable nursing law.

28

Section 806.7.  Public disclosure of staffing requirements.

29

As a condition of licensing, a health care facility required

30

to have a staffing plan under section 806(h) shall:

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1

(1)  Post in a conspicuous place readily accessible to

2

the general public a notice prepared by the department

3

setting forth the mandatory provisions of this act relating

4

to staffing together with a statement of the mandatory and

5

actual daily nurse staffing levels in each nursing department

6

or unit.

7

(2)  Upon request, make copies of the staffing plan filed

8

with the department available to the public.

9

(3)  Make readily available to the nursing staff with a

10

department or unit, during each work shift, the following

11

information:

12

(i)  A copy of the current staffing plan for that

13

department or unit.

14

(ii)  Documentation of the number of direct-care

15

nurses required to be present during the shift based on

16

the approved adopted acuity system.

17

(iii)  Documentation of the actual number of direct-

18

care nurses present during the shift.

19

Section 6.  Section 808(a) of the act, amended December 18,

20

1992 (P.L.1602, No.179), is amended to read:

21

Section 808.  Issuance of license.

22

(a)  Standards.--The department shall issue a license to a

23

health care provider when it is satisfied that the following

24

standards have been met:

25

(1)  that the health care provider is a responsible

26

person;

27

(2)  that the place to be used as a health care facility

28

is adequately constructed, equipped, maintained and operated

29

to safely and efficiently render the services offered;

30

(3)  that the health care facility provides safe and

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1

efficient services which are adequate for the care, treatment

2

and comfort of the patients or residents of such facility;

3

(4)  that there is substantial compliance with the rules

4

and regulations adopted by the department pursuant to this

5

act; [and]

6

(5)  that a certificate of need has been issued if one is

7

necessary[.]; and

8

(6)  that in the case of a health care facility required

9

to have a staffing plan under section 806(h), the facility

10

has submitted a documented staffing plan and is operating in

11

compliance with the requirements of this chapter and

12

applicable regulations.

13

* * *

14

Section 7.  Section 810 of the act is amended by adding a

15

subsection to read:

16

Section 810.  Reliance on accrediting agencies and Federal

17

Government.

18

* * *

19

(d)  Delegation prohibited.--This section shall not be

20

construed to permit the department to delegate any of its

21

functions with respect to the staffing requirements of this

22

chapter.

23

Section 8.  Section 815(c) of the act, added July 12, 1980

24

(P.L.655, No.136), is amended to read:

25

Section 815.  Effect of departmental orders.

26

* * *

27

(c)  Medical assistance payments.--Orders of the department,

28

to the extent that they are sustained by the board, which fail

29

to renew a license or which suspend or revoke a license, shall

30

likewise revoke or suspend certification of the facility as a

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1

medical assistance provider, and no medical assistance payment

2

for services rendered subsequent to the final order shall be

3

made during the pendency of an appeal for the period of

4

revocation or suspension without an order of supersedeas by the

5

appellate court. Any health care facility that falsifies or

6

causes to be falsified documentation required by this act shall

7

be prohibited from receiving any medical assistance payment for

8

a period of six months subsequent to the final order of

9

violation.

10

Section 9.  Section 817(b) of the act, amended December 18,

11

1992 (P.L.1602, No.179), is amended and the section is amended

12

by adding subsections to read:

13

Section 817.  Actions against violations of law, rules and

14

regulations.

15

* * *

16

(b)  Civil penalty.--

17

(1)  Any person, regardless of whether such person is a

18

licensee, who has committed a violation of any of the

19

provisions of this chapter or of any rule or regulation

20

issued pursuant thereto, including failure to correct a

21

serious licensure violation (as defined by regulation) within

22

the time specified in a deficiency citation, may be assessed

23

a civil penalty by an order of the department of up to $500

24

for each deficiency for each day that each deficiency

25

continues[.], provided that a health care facility required

26

to have a staffing plan under section 806(h) that fails to

27

comply with the requirements of section 806.5(c) and

28

reporting requirements of this act may be assessed a civil

29

penalty by an order of the department of up to $10,000 for

30

each day of noncompliance. Civil penalties shall be collected

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1

from the date the facility receives notice of the violation

2

until the department confirms correction of such violation.

3

(2)  Any personal or health care facility that fails to

4

report or falsifies information, or coerces, threatens,

5

intimidates or otherwise influences another person to fail to

6

report or to falsify information required to be reported

7

under this chapter may be assessed a penalty of up to $10,000

8

for each incident.

9

* * *

10

(e)  Discharge or discrimination.--No person shall discharge,

11

discriminate or in any manner retaliate against any employee

12

because the employee has filed a complaint or instituted or

13

caused to be instituted a proceeding under or related to this

14

act or has testified or is about to testify in the proceeding or

15

because of the exercise by the employee on behalf of himself or

16

others of any right afforded by this act.

17

(f)  Private right of action.--Any health care facility other

18

than an extended care facility that violates the rights of an

19

employee set forth in subsection (e) or under an adopted work

20

assignment policy under section 806.6 may be held liable to the

21

employee in an action brought in a court of competent

22

jurisdiction for the legal or equitable relief as may be

23

appropriate to effectuate the purposes of this act, including,

24

but not limited to, reinstatement, promotion, lost wages and

25

benefits and compensatory and consequential damages resulting

26

from the violations together with an equal amount in liquidated

27

damages. The court in the action shall, in addition to any

28

judgment awarded to the plaintiffs, award reasonable attorney

29

fees and costs of action to be paid by the defendants. The

30

employee's right to institute a private action is not limited by

- 16 -

 


1

any other rights granted under this act.

2

Section 10.  The act is amended by adding a section to read:

3

Section 902.2.  Nurse recruitment.

4

(a)  Nurse recruitment grant program.--

5

(1)  The department shall award grants as provided in

6

this section to increase nursing education opportunities.

7

(2)  Eligible entities to whom grants may be provided

8

include the following: a health care facility, a labor

9

organization representing registered nurses in this

10

Commonwealth, or an approved nursing education program for

11

the preparation of professional registered nurses in

12

accordance with the requirements of the professional nursing

13

law.

14

(3)  Grants shall be available to:

15

(i)  Support outreach programs at elementary and

16

secondary schools that inform guidance counselors and

17

students of education opportunities regarding nursing.

18

(ii)  Create demonstration programs to provide

19

mentors for high school students designed to encourage

20

them to enter a career in professional nursing.

21

(iii)  Provide scholarships and/or tuition

22

reimbursement to Pennsylvania residents from diverse

23

racial and ethnic backgrounds who want to become

24

registered nurses. To be eligible for a scholarship or

25

tuition reimbursement, students shall meet designated

26

academic criteria and be accepted into an approved

27

nursing program. Scholarships and/or tuition

28

reimbursement may be conditioned on a commitment of paid

29

service up to three years. Preference for scholarships

30

shall be given to students who are from underrepresented

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1

ethnic and minority backgrounds or who are otherwise

2

under-represented in the profession of nursing. Students

3

who are awarded the scholarships owe the hospital three

4

years of service at full pay or face a penalty of treble

5

the scholarship amount plus interest.

6

(b)  Career ladder grant program.--

7

(1)  The department shall award grants to health care

8

facilities to assist in creating career ladder programs that

9

will encourage employees to obtain the education required to

10

become registered nurses. In making the awards, preference

11

shall be given to health care facilities that have active

12

labor management cooperative programs.

13

(2)  Grants provided under this subsection shall be used

14

to cover costs incurred by employees of the health care

15

facility who enroll in an approved program to become

16

registered nurses, including tuition costs, work release time

17

and dependent care costs.

18

(c)  Nursing facility loan program.--The department shall

19

establish and implement a grant program designed to encourage

20

health care facilities to loan professional nursing staff to

21

serve as faculty at approved nursing schools and/or nursing

22

education programs.

23

Section 11.  This act shall take effect as follows:

24

(1)  The addition of section 902.2 of the act shall take

25

effect in 90 days.

26

(2)  This section shall take effect immediately.

27

(3)  The remainder of this act shall take effect in one

28

year.

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