Florida Senate - 2016 SB 1250
By Senator Latvala
20-01631-16 20161250__
1 A bill to be entitled
2 An act relating to the behavioral health workforce;
3 amending s. 394.453, F.S.; revising legislative
4 intent; amending s. 394.463, F.S.; expanding the
5 authority of a psychiatric nurse to approve the
6 release of a patient from a receiving facility;
7 amending s. 394.467, F.S.; authorizing procedures for
8 recommending admission of a patient to a treatment
9 facility; amending s. 397.451, F.S.; revising
10 provisions relating to exemptions from
11 disqualification for certain service provider
12 personnel; amending s. 409.909, F.S.; adding
13 psychiatry to a list of primary care specialties under
14 the Statewide Medicaid Residency Program; amending s.
15 456.44, F.S.; deleting an obsolete date; requiring
16 advanced registered nurse practitioners and physician
17 assistants who prescribe controlled substances for
18 pain management to make a certain designation, comply
19 with registration requirements, and follow specified
20 standards of practice; providing applicability;
21 providing an effective date.
22
23 Be It Enacted by the Legislature of the State of Florida:
24
25 Section 1. Section 394.453, Florida Statutes, is amended to
26 read:
27 394.453 Legislative intent.—It is the intent of the
28 Legislature to authorize and direct the Department of Children
29 and Families to evaluate, research, plan, and recommend to the
30 Governor and the Legislature programs designed to reduce the
31 occurrence, severity, duration, and disabling aspects of mental,
32 emotional, and behavioral disorders. It is the intent of the
33 Legislature that treatment programs for such disorders shall
34 include, but not be limited to, comprehensive health, social,
35 educational, and rehabilitative services to persons requiring
36 intensive short-term and continued treatment in order to
37 encourage them to assume responsibility for their treatment and
38 recovery. It is intended that such persons be provided with
39 emergency service and temporary detention for evaluation when
40 required; that they be admitted to treatment facilities on a
41 voluntary basis when extended or continuing care is needed and
42 unavailable in the community; that involuntary placement be
43 provided only when expert evaluation determines that it is
44 necessary; that any involuntary treatment or examination be
45 accomplished in a setting which is clinically appropriate and
46 most likely to facilitate the person’s return to the community
47 as soon as possible; and that individual dignity and human
48 rights be guaranteed to all persons who are admitted to mental
49 health facilities or who are being held under s. 394.463. It is
50 the further intent of the Legislature that the least restrictive
51 means of intervention be employed based on the individual needs
52 of each person, within the scope of available services. It is
53 the policy of this state that the use of restraint and seclusion
54 on clients is justified only as an emergency safety measure to
55 be used in response to imminent danger to the client or others.
56 It is, therefore, the intent of the Legislature to achieve an
57 ongoing reduction in the use of restraint and seclusion in
58 programs and facilities serving persons with mental illness. The
59 Legislature further finds the need for additional psychiatrists
60 to be of critical state concern and authorizes the establishment
61 of an additional psychiatry program to be offered by one of
62 Florida’s schools of medicine currently not offering psychiatry.
63 The program shall seek to integrate primary care and psychiatry
64 and other evolving models of care for persons with mental health
65 and substance abuse disorders. Additionally, the Legislature
66 finds that the use of telemedicine for patient evaluation, case
67 management, and ongoing care will improve management of patient
68 care and reduce costs of transportation.
69 Section 2. Paragraph (f) of subsection (2) of section
70 394.463, Florida Statutes, is amended to read:
71 394.463 Involuntary examination.—
72 (2) INVOLUNTARY EXAMINATION.—
73 (f) A patient shall be examined by a physician, a clinical
74 psychologist, or a psychiatric nurse performing within the
75 framework of an established protocol with a psychiatrist at a
76 receiving facility without unnecessary delay and may, upon the
77 order of a physician, be given emergency treatment if it is
78 determined that such treatment is necessary for the safety of
79 the patient or others. The patient may not be released by the
80 receiving facility or its contractor without the documented
81 approval of a psychiatrist, or a clinical psychologist, or, if
82 the receiving facility is owned or operated by a hospital or
83 health system, the release may also be approved by a psychiatric
84 nurse performing within the framework of an established protocol
85 with a psychiatrist or an attending emergency department
86 physician with experience in the diagnosis and treatment of
87 mental and nervous disorders and after completion of an
88 involuntary examination pursuant to this subsection. A
89 psychiatric nurse may not approve the release of a patient if
90 the involuntary examination was initiated by a psychiatrist
91 unless the release is approved by the initiating psychiatrist.
92 However, a patient may not be held in a receiving facility for
93 involuntary examination longer than 72 hours.
94 Section 3. Subsection (2) of section 394.467, Florida
95 Statutes, is amended to read:
96 394.467 Involuntary inpatient placement.—
97 (2) ADMISSION TO A TREATMENT FACILITY.—A patient may be
98 retained by a receiving facility or involuntarily placed in a
99 treatment facility upon the recommendation of the administrator
100 of the receiving facility where the patient has been examined
101 and after adherence to the notice and hearing procedures
102 provided in s. 394.4599. The recommendation must be supported by
103 the opinion of a psychiatrist and the second opinion of a
104 clinical psychologist or another psychiatrist, both of whom have
105 personally examined the patient within the preceding 72 hours,
106 that the criteria for involuntary inpatient placement are met.
107 However, in a county that has a population of fewer than 50,000,
108 if the administrator certifies that a psychiatrist or clinical
109 psychologist is not available to provide the second opinion, the
110 second opinion may be provided by a licensed physician who has
111 postgraduate training and experience in diagnosis and treatment
112 of mental and nervous disorders or by a psychiatric nurse. Any
113 second opinion authorized in this subsection may be conducted
114 through a face-to-face examination, in person or by electronic
115 means. Such recommendation shall be entered on an involuntary
116 inpatient placement certificate that authorizes the receiving
117 facility to retain the patient pending transfer to a treatment
118 facility or completion of a hearing.
119 Section 4. Paragraphs (e) and (f) of subsection (1) and
120 paragraph (b) of subsection (4) of section 397.451, Florida
121 Statutes, are amended to read:
122 397.451 Background checks of service provider personnel.—
123 (1) PERSONNEL BACKGROUND CHECKS; REQUIREMENTS AND
124 EXCEPTIONS.—
125 (e) Personnel employed directly or under contract with the
126 Department of Corrections in an inmate substance abuse program
127 who have direct contact with unmarried inmates under the age of
128 18 or with inmates who are developmentally disabled are exempt
129 from the fingerprinting and background check requirements of
130 this section unless they have direct contact with unmarried
131 inmates under the age of 18 or with inmates who are
132 developmentally disabled.
133 (f) Service provider personnel who request an exemption
134 from disqualification must submit the request within 30 days
135 after being notified of the disqualification. If 5 years or more
136 have elapsed since the most recent disqualifying offense,
137 service provider personnel may work with adults with substance
138 use disorders under the supervision of a qualified professional
139 licensed under chapter 490 or chapter 491 or a master’s level
140 certified addiction professional until the agency makes a final
141 determination regarding the request for an exemption from
142 disqualification Upon notification of the disqualification, the
143 service provider shall comply with requirements regarding
144 exclusion from employment in s. 435.06.
145 (4) EXEMPTIONS FROM DISQUALIFICATION.—
146 (b) Since rehabilitated substance abuse impaired persons
147 are effective in the successful treatment and rehabilitation of
148 individuals with substance use disorders substance abuse
149 impaired adolescents, for service providers which treat
150 adolescents 13 years of age and older, service provider
151 personnel whose background checks indicate crimes under s.
152 817.563, s. 893.13, or s. 893.147 may be exempted from
153 disqualification from employment pursuant to this paragraph.
154 Section 5. Paragraph (a) of subsection (2) of section
155 409.909, Florida Statutes, is amended to read:
156 409.909 Statewide Medicaid Residency Program.—
157 (2) On or before September 15 of each year, the agency
158 shall calculate an allocation fraction to be used for
159 distributing funds to participating hospitals. On or before the
160 final business day of each quarter of a state fiscal year, the
161 agency shall distribute to each participating hospital one
162 fourth of that hospital’s annual allocation calculated under
163 subsection (4). The allocation fraction for each participating
164 hospital is based on the hospital’s number of full-time
165 equivalent residents and the amount of its Medicaid payments. As
166 used in this section, the term:
167 (a) “Full-time equivalent,” or “FTE,” means a resident who
168 is in his or her residency period, with the initial residency
169 period defined as the minimum number of years of training
170 required before the resident may become eligible for board
171 certification by the American Osteopathic Association Bureau of
172 Osteopathic Specialists or the American Board of Medical
173 Specialties in the specialty in which he or she first began
174 training, not to exceed 5 years. The residency specialty is
175 defined as reported using the current residency type codes in
176 the Intern and Resident Information System (IRIS), required by
177 Medicare. A resident training beyond the initial residency
178 period is counted as 0.5 FTE, unless his or her chosen specialty
179 is in primary care, in which case the resident is counted as 1.0
180 FTE. For the purposes of this section, primary care specialties
181 include:
182 1. Family medicine;
183 2. General internal medicine;
184 3. General pediatrics;
185 4. Preventive medicine;
186 5. Geriatric medicine;
187 6. Osteopathic general practice;
188 7. Obstetrics and gynecology;
189 8. Emergency medicine; and
190 9. General surgery; and.
191 10. Psychiatry.
192 Section 6. Subsections (2) and (3) of section 456.44,
193 Florida Statutes, are amended to read:
194 456.44 Controlled substance prescribing.—
195 (2) REGISTRATION.—Effective January 1, 2012, A physician
196 licensed under chapter 458, chapter 459, chapter 461, or chapter
197 466, a physician assistant licensed under chapter 458 or chapter
198 459, or an advanced registered nurse practitioner certified
199 under part I of chapter 464 who prescribes any controlled
200 substance, listed in Schedule II, Schedule III, or Schedule IV
201 as defined in s. 893.03, for the treatment of chronic
202 nonmalignant pain, must:
203 (a) Designate himself or herself as a controlled substance
204 prescribing practitioner on his or her the physician’s
205 practitioner profile.
206 (b) Comply with the requirements of this section and
207 applicable board rules.
208 (3) STANDARDS OF PRACTICE.—The standards of practice in
209 this section do not supersede the level of care, skill, and
210 treatment recognized in general law related to health care
211 licensure.
212 (a) A complete medical history and a physical examination
213 must be conducted before beginning any treatment and must be
214 documented in the medical record. The exact components of the
215 physical examination shall be left to the judgment of the
216 registrant clinician who is expected to perform a physical
217 examination proportionate to the diagnosis that justifies a
218 treatment. The medical record must, at a minimum, document the
219 nature and intensity of the pain, current and past treatments
220 for pain, underlying or coexisting diseases or conditions, the
221 effect of the pain on physical and psychological function, a
222 review of previous medical records, previous diagnostic studies,
223 and history of alcohol and substance abuse. The medical record
224 shall also document the presence of one or more recognized
225 medical indications for the use of a controlled substance. Each
226 registrant must develop a written plan for assessing each
227 patient’s risk of aberrant drug-related behavior, which may
228 include patient drug testing. Registrants must assess each
229 patient’s risk for aberrant drug-related behavior and monitor
230 that risk on an ongoing basis in accordance with the plan.
231 (b) Each registrant must develop a written individualized
232 treatment plan for each patient. The treatment plan shall state
233 objectives that will be used to determine treatment success,
234 such as pain relief and improved physical and psychosocial
235 function, and shall indicate if any further diagnostic
236 evaluations or other treatments are planned. After treatment
237 begins, the registrant physician shall adjust drug therapy to
238 the individual medical needs of each patient. Other treatment
239 modalities, including a rehabilitation program, shall be
240 considered depending on the etiology of the pain and the extent
241 to which the pain is associated with physical and psychosocial
242 impairment. The interdisciplinary nature of the treatment plan
243 shall be documented.
244 (c) The registrant physician shall discuss the risks and
245 benefits of the use of controlled substances, including the
246 risks of abuse and addiction, as well as physical dependence and
247 its consequences, with the patient, persons designated by the
248 patient, or the patient’s surrogate or guardian if the patient
249 is incompetent. The registrant physician shall use a written
250 controlled substance agreement between the registrant physician
251 and the patient outlining the patient’s responsibilities,
252 including, but not limited to:
253 1. Number and frequency of controlled substance
254 prescriptions and refills.
255 2. Patient compliance and reasons for which drug therapy
256 may be discontinued, such as a violation of the agreement.
257 3. An agreement that controlled substances for the
258 treatment of chronic nonmalignant pain shall be prescribed by a
259 single treating registrant physician unless otherwise authorized
260 by the treating registrant physician and documented in the
261 medical record.
262 (d) The patient shall be seen by the registrant physician
263 at regular intervals, not to exceed 3 months, to assess the
264 efficacy of treatment, ensure that controlled substance therapy
265 remains indicated, evaluate the patient’s progress toward
266 treatment objectives, consider adverse drug effects, and review
267 the etiology of the pain. Continuation or modification of
268 therapy shall depend on the registrant’s physician’s evaluation
269 of the patient’s progress. If treatment goals are not being
270 achieved, despite medication adjustments, the registrant
271 physician shall reevaluate the appropriateness of continued
272 treatment. The registrant physician shall monitor patient
273 compliance in medication usage, related treatment plans,
274 controlled substance agreements, and indications of substance
275 abuse or diversion at a minimum of 3-month intervals.
276 (e) The registrant physician shall refer the patient as
277 necessary for additional evaluation and treatment in order to
278 achieve treatment objectives. Special attention shall be given
279 to those patients who are at risk for misusing their medications
280 and those whose living arrangements pose a risk for medication
281 misuse or diversion. The management of pain in patients with a
282 history of substance abuse or with a comorbid psychiatric
283 disorder requires extra care, monitoring, and documentation and
284 requires consultation with or referral to an addiction medicine
285 specialist or psychiatrist.
286 (f) A registrant physician registered under this section
287 must maintain accurate, current, and complete records that are
288 accessible and readily available for review and comply with the
289 requirements of this section, the applicable practice act, and
290 applicable board rules. The medical records must include, but
291 are not limited to:
292 1. The complete medical history and a physical examination,
293 including history of drug abuse or dependence.
294 2. Diagnostic, therapeutic, and laboratory results.
295 3. Evaluations and consultations.
296 4. Treatment objectives.
297 5. Discussion of risks and benefits.
298 6. Treatments.
299 7. Medications, including date, type, dosage, and quantity
300 prescribed.
301 8. Instructions and agreements.
302 9. Periodic reviews.
303 10. Results of any drug testing.
304 11. A photocopy of the patient’s government-issued photo
305 identification.
306 12. If a written prescription for a controlled substance is
307 given to the patient, a duplicate of the prescription.
308 13. The registrant’s physician’s full name presented in a
309 legible manner.
310 (g) Patients with signs or symptoms of substance abuse
311 shall be immediately referred to a board-certified pain
312 management physician, an addiction medicine specialist, or a
313 mental health addiction facility as it pertains to drug abuse or
314 addiction unless the registrant is a physician who is board
315 certified or board-eligible in pain management. Throughout the
316 period of time before receiving the consultant’s report, a
317 prescribing registrant physician shall clearly and completely
318 document medical justification for continued treatment with
319 controlled substances and those steps taken to ensure medically
320 appropriate use of controlled substances by the patient. Upon
321 receipt of the consultant’s written report, the prescribing
322 registrant physician shall incorporate the consultant’s
323 recommendations for continuing, modifying, or discontinuing
324 controlled substance therapy. The resulting changes in treatment
325 shall be specifically documented in the patient’s medical
326 record. Evidence or behavioral indications of diversion shall be
327 followed by discontinuation of controlled substance therapy, and
328 the patient shall be discharged, and all results of testing and
329 actions taken by the registrant physician shall be documented in
330 the patient’s medical record.
331
332 This subsection does not apply to a board-eligible or board
333 certified anesthesiologist, physiatrist, rheumatologist, or
334 neurologist, or to a board-certified physician who has surgical
335 privileges at a hospital or ambulatory surgery center and
336 primarily provides surgical services. This subsection does not
337 apply to a board-eligible or board-certified medical specialist
338 who has also completed a fellowship in pain medicine approved by
339 the Accreditation Council for Graduate Medical Education or the
340 American Osteopathic Association, or who is board eligible or
341 board certified in pain medicine by the American Board of Pain
342 Medicine, the American Board of Interventional Pain Physicians,
343 the American Association of Physician Specialists, or a board
344 approved by the American Board of Medical Specialties or the
345 American Osteopathic Association and performs interventional
346 pain procedures of the type routinely billed using surgical
347 codes. This subsection does not apply to a registrant, advanced
348 registered nurse practitioner, or physician assistant who
349 prescribes medically necessary controlled substances for a
350 patient during an inpatient stay in a hospital licensed under
351 chapter 395.
352 Section 7. This act shall take effect July 1, 2016.