Florida Senate - 2019                              CS for SB 732
       
       
        
       By the Committee on Health Policy; and Senator Flores
       
       
       
       
       
       588-02904-19                                           2019732c1
    1                        A bill to be entitled                      
    2         An act relating to clinics and office surgery;
    3         amending s. 400.9905, F.S.; revising the definition of
    4         the term “clinic”; amending s. 400.991, F.S.;
    5         requiring a clinic to provide proof of its financial
    6         responsibility to pay certain claims and costs along
    7         with its application for licensure to the Agency for
    8         Health Care Administration; amending s. 400.9935,
    9         F.S.; requiring a medical director or a clinic
   10         director to ensure that the clinic complies with
   11         specified rules; amending s. 400.995, F.S.; requiring
   12         the agency to impose a specified administrative fine
   13         on an unregistered clinic that performs certain office
   14         surgeries; amending s. 456.004, F.S.; requiring the
   15         Department of Health to deny or revoke the
   16         registration of or impose certain penalties against a
   17         facility where certain office surgeries are performed
   18         under certain circumstances; specifying provisions
   19         that apply enforcement actions against such
   20         facilities; authorizing the department to deny certain
   21         persons associated with an office of which the
   22         registration was revoked from registering a new office
   23         to perform certain office surgery; amending s.
   24         456.074, F.S.; authorizing the department to issue an
   25         emergency order suspending or restricting the
   26         registration of a certain office if it makes certain
   27         findings; amending s. 458.305, F.S.; defining terms;
   28         amending s. 458.309, F.S.; requiring a physician who
   29         performs certain office surgery and the office in
   30         which the surgery is performed to maintain specified
   31         levels of financial responsibility; authorizing the
   32         department to adopt rules to administer the
   33         registration, inspection, and safety of offices that
   34         perform certain office surgery; requiring the Board of
   35         Medicine to adopt rules governing the standard of care
   36         for physicians practicing in such offices; requiring
   37         the board to impose a specified fine on physicians who
   38         perform certain office surgeries in an unregistered
   39         office; amending s. 458.331, F.S.; providing that a
   40         physician performing certain office surgeries in an
   41         unregistered office constitutes grounds for denial of
   42         a license or disciplinary action; amending s. 459.003,
   43         F.S.; defining terms; amending s. 459.005, F.S.;
   44         requiring a physician who performs certain office
   45         surgery and the office in which the surgery is
   46         performed to maintain specified levels of financial
   47         responsibility; authorizing the department to adopt
   48         rules to administer the registration, inspection, and
   49         safety of offices that perform certain office surgery;
   50         requiring the Board of Osteopathic Medicine to adopt
   51         rules governing the standard of care for physicians
   52         practicing in such offices; requiring the board to
   53         impose a specified fine on physicians who perform
   54         certain office surgeries in an unregistered office;
   55         amending s. 459.015, F.S.; providing that a physician
   56         performing certain office surgeries in an unregistered
   57         office constitutes grounds for denial of a license or
   58         disciplinary action; amending s. 464.012, F.S.;
   59         authorizing a certified registered nurse anesthetist
   60         to provide specified services in a an office
   61         registered to perform office surgery within the
   62         framework of an established protocol with a licensed
   63         anesthesiologist; amending s. 766.101, F.S.;
   64         conforming a cross-reference; providing an effective
   65         date.
   66          
   67  Be It Enacted by the Legislature of the State of Florida:
   68  
   69         Section 1. Subsection (4) of section 400.9905, Florida
   70  Statutes, is amended to read:
   71         400.9905 Definitions.—
   72         (4) “Clinic” means an entity that provides where health
   73  care services are provided to individuals and that receives
   74  compensation and which tenders charges for reimbursement for
   75  those such services, including a mobile clinic and a portable
   76  equipment provider. As used in this part, the term does not
   77  include and the licensure requirements of this part do not apply
   78  to:
   79         (a) Entities licensed or registered by the state under
   80  chapter 395; entities licensed or registered by the state and
   81  providing only health care services within the scope of services
   82  authorized under their respective licenses under ss. 383.30
   83  383.332, chapter 390, chapter 394, chapter 397, this chapter
   84  except part X, chapter 429, chapter 463, chapter 465, chapter
   85  466, chapter 478, chapter 484, or chapter 651; end-stage renal
   86  disease providers authorized under 42 C.F.R. part 405, subpart
   87  U; providers certified under 42 C.F.R. part 485, subpart B or
   88  subpart H; or any entity that provides neonatal or pediatric
   89  hospital-based health care services or other health care
   90  services by licensed practitioners solely within a hospital
   91  licensed under chapter 395.
   92         (b) Entities that own, directly or indirectly, entities
   93  licensed or registered by the state pursuant to chapter 395;
   94  entities that own, directly or indirectly, entities licensed or
   95  registered by the state and providing only health care services
   96  within the scope of services authorized pursuant to their
   97  respective licenses under ss. 383.30-383.332, chapter 390,
   98  chapter 394, chapter 397, this chapter except part X, chapter
   99  429, chapter 463, chapter 465, chapter 466, chapter 478, chapter
  100  484, or chapter 651; end-stage renal disease providers
  101  authorized under 42 C.F.R. part 405, subpart U; providers
  102  certified under 42 C.F.R. part 485, subpart B or subpart H; or
  103  any entity that provides neonatal or pediatric hospital-based
  104  health care services by licensed practitioners solely within a
  105  hospital licensed under chapter 395.
  106         (c) Entities that are owned, directly or indirectly, by an
  107  entity licensed or registered by the state pursuant to chapter
  108  395; entities that are owned, directly or indirectly, by an
  109  entity licensed or registered by the state and providing only
  110  health care services within the scope of services authorized
  111  pursuant to their respective licenses under ss. 383.30-383.332,
  112  chapter 390, chapter 394, chapter 397, this chapter except part
  113  X, chapter 429, chapter 463, chapter 465, chapter 466, chapter
  114  478, chapter 484, or chapter 651; end-stage renal disease
  115  providers authorized under 42 C.F.R. part 405, subpart U;
  116  providers certified under 42 C.F.R. part 485, subpart B or
  117  subpart H; or any entity that provides neonatal or pediatric
  118  hospital-based health care services by licensed practitioners
  119  solely within a hospital under chapter 395.
  120         (d) Entities that are under common ownership, directly or
  121  indirectly, with an entity licensed or registered by the state
  122  pursuant to chapter 395; entities that are under common
  123  ownership, directly or indirectly, with an entity licensed or
  124  registered by the state and providing only health care services
  125  within the scope of services authorized pursuant to their
  126  respective licenses under ss. 383.30-383.332, chapter 390,
  127  chapter 394, chapter 397, this chapter except part X, chapter
  128  429, chapter 463, chapter 465, chapter 466, chapter 478, chapter
  129  484, or chapter 651; end-stage renal disease providers
  130  authorized under 42 C.F.R. part 405, subpart U; providers
  131  certified under 42 C.F.R. part 485, subpart B or subpart H; or
  132  any entity that provides neonatal or pediatric hospital-based
  133  health care services by licensed practitioners solely within a
  134  hospital licensed under chapter 395.
  135         (e) An entity that is exempt from federal taxation under 26
  136  U.S.C. s. 501(c)(3) or (4), an employee stock ownership plan
  137  under 26 U.S.C. s. 409 that has a board of trustees at least
  138  two-thirds of which are Florida-licensed health care
  139  practitioners and provides only physical therapy services under
  140  physician orders, any community college or university clinic,
  141  and any entity owned or operated by the federal or state
  142  government, including agencies, subdivisions, or municipalities
  143  thereof.
  144         (f) A sole proprietorship, group practice, partnership, or
  145  corporation that provides health care services by physicians
  146  covered by s. 627.419, that is directly supervised by one or
  147  more of such physicians, and that is wholly owned by one or more
  148  of those physicians or by a physician and the spouse, parent,
  149  child, or sibling of that physician.
  150         (g) A sole proprietorship, group practice, partnership, or
  151  corporation that provides health care services by licensed
  152  health care practitioners under chapter 457, chapter 458,
  153  chapter 459, chapter 460, chapter 461, chapter 462, chapter 463,
  154  chapter 466, chapter 467, chapter 480, chapter 484, chapter 486,
  155  chapter 490, chapter 491, or part I, part III, part X, part
  156  XIII, or part XIV of chapter 468, or s. 464.012, and that is
  157  wholly owned by one or more licensed health care practitioners,
  158  or the licensed health care practitioners set forth in this
  159  paragraph and the spouse, parent, child, or sibling of a
  160  licensed health care practitioner if one of the owners who is a
  161  licensed health care practitioner is supervising the business
  162  activities and is legally responsible for the entity’s
  163  compliance with all federal and state laws. However, a health
  164  care practitioner may not supervise services beyond the scope of
  165  the practitioner’s license, except that, for the purposes of
  166  this part, a clinic owned by a licensee in s. 456.053(3)(b)
  167  which provides only services authorized pursuant to s.
  168  456.053(3)(b) may be supervised by a licensee specified in s.
  169  456.053(3)(b).
  170         (h) Clinical facilities affiliated with an accredited
  171  medical school at which training is provided for medical
  172  students, residents, or fellows.
  173         (i) Entities that provide only oncology or radiation
  174  therapy services by physicians licensed under chapter 458 or
  175  chapter 459 or entities that provide oncology or radiation
  176  therapy services by physicians licensed under chapter 458 or
  177  chapter 459 which are owned by a corporation whose shares are
  178  publicly traded on a recognized stock exchange.
  179         (j) Clinical facilities affiliated with a college of
  180  chiropractic accredited by the Council on Chiropractic Education
  181  at which training is provided for chiropractic students.
  182         (k) Entities that provide licensed practitioners to staff
  183  emergency departments or to deliver anesthesia services in
  184  facilities licensed under chapter 395 and that derive at least
  185  90 percent of their gross annual revenues from the provision of
  186  such services. Entities claiming an exemption from licensure
  187  under this paragraph must provide documentation demonstrating
  188  compliance.
  189         (l) Orthotic, prosthetic, pediatric cardiology, or
  190  perinatology clinical facilities or anesthesia clinical
  191  facilities that are not otherwise exempt under paragraph (a) or
  192  paragraph (k) and that are a publicly traded corporation or are
  193  wholly owned, directly or indirectly, by a publicly traded
  194  corporation. As used in this paragraph, a publicly traded
  195  corporation is a corporation that issues securities traded on an
  196  exchange registered with the United States Securities and
  197  Exchange Commission as a national securities exchange.
  198         (m) Entities that are owned by a corporation that has $250
  199  million or more in total annual sales of health care services
  200  provided by licensed health care practitioners where one or more
  201  of the persons responsible for the operations of the entity is a
  202  health care practitioner who is licensed in this state and who
  203  is responsible for supervising the business activities of the
  204  entity and is responsible for the entity’s compliance with state
  205  law for purposes of this part.
  206         (n) Entities that employ 50 or more licensed health care
  207  practitioners licensed under chapter 458 or chapter 459 where
  208  the billing for medical services is under a single tax
  209  identification number. The application for exemption under this
  210  subsection shall contain information that includes: the name,
  211  residence, and business address and phone number of the entity
  212  that owns the practice; a complete list of the names and contact
  213  information of all the officers and directors of the
  214  corporation; the name, residence address, business address, and
  215  medical license number of each licensed Florida health care
  216  practitioner employed by the entity; the corporate tax
  217  identification number of the entity seeking an exemption; a
  218  listing of health care services to be provided by the entity at
  219  the health care clinics owned or operated by the entity and a
  220  certified statement prepared by an independent certified public
  221  accountant which states that the entity and the health care
  222  clinics owned or operated by the entity have not received
  223  payment for health care services under personal injury
  224  protection insurance coverage for the preceding year. If the
  225  agency determines that an entity which is exempt under this
  226  subsection has received payments for medical services under
  227  personal injury protection insurance coverage, the agency may
  228  deny or revoke the exemption from licensure under this
  229  subsection.
  230  
  231  Notwithstanding this subsection, an entity shall be deemed a
  232  clinic and must be licensed under this part in order to receive
  233  reimbursement under the Florida Motor Vehicle No-Fault Law, ss.
  234  627.730-627.7405, unless exempted under s. 627.736(5)(h).
  235         Section 2. Subsection (4) of section 400.991, Florida
  236  Statutes, is amended to read:
  237         400.991 License requirements; background screenings;
  238  prohibitions.—
  239         (4) In addition to the requirements of part II of chapter
  240  408, the applicant must file with the application satisfactory
  241  proof that the clinic is in compliance with this part and
  242  applicable rules, including:
  243         (a) A listing of services to be provided either directly by
  244  the applicant or through contractual arrangements with existing
  245  providers;
  246         (b) The number and discipline of each professional staff
  247  member to be employed; and
  248         (c) Proof of financial ability to operate as required under
  249  s. 408.810(8). As an alternative to submitting proof of
  250  financial ability to operate as required under s. 408.810(8),
  251  the applicant may file a surety bond of at least $500,000 which
  252  guarantees that the clinic will act in full conformity with all
  253  legal requirements for operating a clinic, payable to the
  254  agency. The agency may adopt rules to specify related
  255  requirements for such surety bond; and
  256         (d) Proof that the clinic maintains the financial
  257  responsibility in the manner set forth in s. 458.320(2) or s.
  258  459.0085(2), as applicable, to pay claims and costs ancillary
  259  thereto arising out of the rendering of or the failure to render
  260  medical care and services, for physicians and osteopathic
  261  physicians who perform liposuction procedures in which more than
  262  1,000 cubic centimeters of supernatant fat is removed, Level II
  263  office surgery, or Level III office surgery as those terms are
  264  defined in ss. 458.305(8) and 459.003(9), in an office setting.
  265         Section 3. Paragraph (j) is added to subsection (1) of
  266  section 400.9935, Florida Statutes, to read:
  267         400.9935 Clinic responsibilities.—
  268         (1) Each clinic shall appoint a medical director or clinic
  269  director who shall agree in writing to accept legal
  270  responsibility for the following activities on behalf of the
  271  clinic. The medical director or the clinic director shall:
  272         (j) If the clinic is registered with the department to
  273  perform office surgery, ensure that the clinic complies with the
  274  standards of practice for office surgery adopted by rule under
  275  ss. 458.309(4) and 459.005(3).
  276         Section 4. Subsection (4) of section 400.995, Florida
  277  Statutes, is amended to read:
  278         400.995 Agency administrative penalties.—
  279         (4) Any licensed clinic whose owner, medical director, or
  280  clinic director concurrently operates an unlicensed clinic or a
  281  clinic that is not registered with the department where any
  282  liposuction procedure in which more than 1,000 cubic centimeters
  283  of supernatant fat is removed or where any Level II office
  284  surgery or Level III office surgery, as those terms are defined
  285  in ss. 458.305(8) and 459.003(9), is performed, is shall be
  286  subject to an administrative fine of $5,000 per day.
  287         Section 5. Subsection (12) is added to section 456.004,
  288  Florida Statutes, to read:
  289         456.004 Department; powers and duties.—The department, for
  290  the professions under its jurisdiction, shall:
  291         (12) Deny or revoke the registration of, or impose any
  292  penalty set forth in s. 456.072(2) against, any facility where
  293  office surgery, as defined in ss. 458.305(8) and 459.003(9), is
  294  performed for failure of any of its physicians, owners, or
  295  operators to comply with rules adopted under ss. 458.309(3) and
  296  459.005(2). Section 456.073 applies to enforcement actions
  297  brought against such facilities. If a facility’s registration is
  298  revoked, the department may deny any person named in the
  299  registration documents of the facility, including the persons
  300  who own or operate the facility, individually or as part of a
  301  group, from registering a facility to perform surgical
  302  procedures pursuant to s. 458.309(3) or s. 459.005(2) for 5
  303  years after the revocation date.
  304         Section 6. Subsection (6) is added to section 456.074,
  305  Florida Statutes, to read:
  306         456.074 Certain health care practitioners; immediate
  307  suspension of license.—
  308         (6) The department may issue an emergency order suspending
  309  or restricting the registration of a facility in which
  310  liposuction procedures in which more than 1,000 cubic
  311  centimeters of supernatant fat is removed, Level II office
  312  surgery, or Level III office surgery as those terms are defined
  313  in ss. 458.305(8) and 459.003(9), are performed upon a finding
  314  of probable cause that the facility or its surgeons are not in
  315  compliance with the standards of practice for office surgery
  316  adopted by the boards pursuant to s. 458.309(4) or s.
  317  459.005(3), as applicable, or are in violation of s.
  318  458.331(1)(v) or s. 459.015(1)(z) and that such noncompliance
  319  constitutes an immediate danger to the public.
  320         Section 7. Section 458.305, Florida Statutes, is amended to
  321  read:
  322         458.305 Definitions.—As used in this chapter, the term:
  323         (1) “Board” means the Board of Medicine.
  324         (2)“Deep sedation and analgesia” means a drug-induced
  325  depression of consciousness during which all of the following
  326  apply:
  327         (a) The patient cannot be easily aroused but responds by
  328  purposefully following repeated or painful stimulation.
  329         (b) The patient’s ability to independently maintain
  330  ventilatory function may be impaired.
  331         (c) The patient may require assistance in maintaining a
  332  patent airway, and spontaneous ventilation may be inadequate.
  333         (d) The patient’s cardiovascular function is usually
  334  maintained.
  335         (e) The patient’s reflex withdrawal from painful stimulus
  336  is not considered a purposeful response.
  337         (3)(2) “Department” means the Department of Health.
  338         (4)“Epidural anesthesia” means anesthesia produced by the
  339  injection of an anesthetic agent into the space on or around the
  340  dura mater of the spinal cord.
  341         (5)“General anesthesia” means a drug-induced loss of
  342  consciousness administered by a qualified general anesthesia
  343  provider during which all of the following apply:
  344         (a) The patient is not able to be aroused, even by painful
  345  stimulation.
  346         (b) The patient’s ability to independently maintain
  347  ventilatory function is often impaired.
  348         (c) The patient has a level of depressed neuromuscular
  349  function.
  350         (d) The patient may require assistance in maintaining a
  351  patent airway, and positive pressure ventilation may be
  352  required.
  353         (e) The patient’s cardiovascular function may be impaired.
  354         (6)“Minimal sedation” means a drug-induced state during
  355  which patients respond normally to verbal commands. Although
  356  cognitive function and physical coordination may be impaired,
  357  airway reflexes and respiratory and cardiovascular functions are
  358  unaffected.
  359         (7) “Moderate sedation and analgesia” or “conscious
  360  sedation” means drug-induced depression of consciousness and a
  361  state of consciousness during which all of the following apply:
  362         (a) The patient responds purposefully to verbal commands,
  363  either alone or accompanied by light tactile stimulation.
  364         (b) Interventions are not required to maintain a patent
  365  airway, and spontaneous ventilation is adequate.
  366         (c) Cardiovascular function is maintained.
  367         (d) Reflex withdrawal from a painful stimulus is not
  368  considered a purposeful response.
  369         (8)“Office surgery” means a surgery that is performed in a
  370  physician’s office or any facility that is not licensed under
  371  chapter 390 or chapter 395.
  372         (a)“Level I office surgery” includes any surgery that
  373  consists of only minor procedures and in which anesthesia is
  374  limited to minimal sedation.
  375         (b)“Level II office surgery includes any surgery in which
  376  the patient’s level of sedation is that of moderate sedation and
  377  analgesia or conscious sedation.
  378         (c) ”Level III office surgery includes any surgery in
  379  which the patient’s level of sedation is that of deep sedation
  380  and analgesia or general anesthesia. The term includes any
  381  surgery that includes the use of spinal anesthesia or epidural
  382  anesthesia.
  383         (10)(3) “Practice of medicine” means the diagnosis,
  384  treatment, operation, or prescription for any human disease,
  385  pain, injury, deformity, or other physical or mental condition.
  386         (11)“Spinal anesthesia” means anesthesia produced by the
  387  injection of an anesthetic agent into the subarachnoid space of
  388  the spinal cord.
  389         (12)“Surgeon” means a physician who performs surgery.
  390         (13)“Surgery” means any manual or operative procedure,
  391  including the use of lasers, performed upon the body of a living
  392  human being for the purposes of preserving health, diagnosing or
  393  curing disease, repairing injury, correcting deformity or
  394  defects, prolonging life, or relieving suffering or any elective
  395  procedure for aesthetic, reconstructive, or cosmetic purposes,
  396  including, but not limited to: incision or curettage of tissue
  397  or an organ; suture or other repair of tissue or organ,
  398  including a closed as well as an open reduction of a fracture;
  399  extraction of tissue including premature extraction of the
  400  products of conception from the uterus; insertion of natural or
  401  artificial implants; or an endoscopic procedure with use of
  402  local or general anesthetic.
  403         (9)(4) “Physician” means a person who is licensed to
  404  practice medicine in this state.
  405         Section 8. Subsection (3) of section 458.309, Florida
  406  Statutes, is amended and subsection (4) is added to that
  407  section, to read:
  408         458.309 Rulemaking authority.—
  409         (3) A physician who performs any liposuction procedure
  410  procedures in which more than 1,000 cubic centimeters of
  411  supernatant fat is removed, any Level II office surgery level 2
  412  procedures lasting more than 5 minutes, or any Level III office
  413  surgery and all level 3 surgical procedures in an office setting
  414  must register the office with the department unless that office
  415  is licensed as a facility under chapter 395. The department
  416  shall inspect the physician’s office annually unless the office
  417  is accredited by a nationally recognized accrediting agency or
  418  an accrediting organization subsequently approved by the Board
  419  of Medicine. The actual costs for registration and inspection or
  420  accreditation shall be paid by the person seeking to register
  421  and operate the office setting in which office surgery is
  422  performed. As a condition of registration, a physician who
  423  performs such surgical procedures in an office setting, and the
  424  office itself if it is a separate legal entity from the
  425  physician, must maintain the same levels of financial
  426  responsibility required in s. 458.320.
  427         (4) The department may adopt rules to administer the
  428  registration, inspection, and safety of offices in which a
  429  physician performs office surgery. The board shall adopt by rule
  430  standards of practice for physicians who perform office surgery.
  431  The board shall impose a fine of $5,000 per day on a physician
  432  who performs a surgical procedure identified in subsection (3)
  433  in an office that is not registered with the department.
  434         Section 9. Paragraph (vv) is added to subsection (1) of
  435  section 458.331, Florida Statutes, to read:
  436         458.331 Grounds for disciplinary action; action by the
  437  board and department.—
  438         (1) The following acts constitute grounds for denial of a
  439  license or disciplinary action, as specified in s. 456.072(2):
  440         (vv) Performing a liposuction procedure in which more than
  441  1,000 cubic centimeters of supernatant fat is removed, a Level
  442  II office surgery, or a Level III office surgery in an office
  443  that is not registered with the department pursuant to s.
  444  458.309(3).
  445         Section 10. Section 459.003, Florida Statutes, is amended
  446  to read:
  447         459.003 Definitions.—As used in this chapter, the term:
  448         (1) “Board” means the Board of Osteopathic Medicine.
  449         (2)“Deep sedation and analgesia” means a drug-induced
  450  depression of consciousness during which all of the following
  451  apply:
  452         (a) The patient cannot be easily aroused but responds by
  453  purposefully following repeated or painful stimulation.
  454         (b) The patient’s ability to independently maintain
  455  ventilatory function may be impaired.
  456         (c) The patient may require assistance in maintaining a
  457  patent airway, and spontaneous ventilation may be inadequate.
  458         (d) The patient’s cardiovascular function is usually
  459  maintained.
  460         (e) The patient’s reflex withdrawal from painful stimulus
  461  is not considered a purposeful response.
  462         (3)(2) “Department” means the Department of Health.
  463         (5)“Epidural anesthesia” means anesthesia produced by the
  464  injection of an anesthetic agent into the space on or around the
  465  dura mater of the spinal cord.
  466         (6)“General anesthesia” means a drug-induced loss of
  467  consciousness administered by a qualified general anesthesia
  468  provider during which all of the following apply:
  469         (a) The patient is not able to be aroused, even by painful
  470  stimulation.
  471         (b) The patient’s ability to independently maintain
  472  ventilatory function is often impaired.
  473         (c) The patient has a level of depressed neuromuscular
  474  function.
  475         (d) The patient may require assistance in maintaining a
  476  patent airway, and positive pressure ventilation may be
  477  required.
  478         (e) The patient’s cardiovascular function may be impaired.
  479         (7)“Minimal sedation” means a drug-induced state during
  480  which patients respond normally to verbal commands. Although
  481  cognitive function and physical coordination may be impaired,
  482  airway reflexes, and respiratory and cardiovascular functions
  483  are unaffected.
  484         (8) “Moderate sedation and analgesia” or “conscious
  485  sedation” means drug-induced depression of consciousness and a
  486  state of consciousness during which all of the following apply:
  487         (a) The patient responds purposefully to verbal commands,
  488  either alone or accompanied by light tactile stimulation.
  489         (b) Interventions are not required to maintain a patent
  490  airway, and spontaneous ventilation is adequate.
  491         (c) Cardiovascular function is maintained.
  492         (d) Reflex withdrawal from a painful stimulus is not
  493  considered a purposeful response.
  494         (9)“Office surgery” means a surgery that is performed in a
  495  physician’s office or any facility that is not licensed under
  496  chapter 390 or chapter 395.
  497         (a)“Level I office surgery” includes any surgery that
  498  consists of only minor procedures and in which anesthesia is
  499  limited to minimal sedation.
  500         (b)“Level II office surgery includes any surgery in which
  501  the patient’s level of sedation is that of moderate sedation and
  502  analgesia or conscious sedation.
  503         (c) ”Level III office surgery includes any surgery in
  504  which the patient’s level of sedation is that of deep sedation
  505  and analgesia or general anesthesia. The term includes any
  506  surgery that includes the use of spinal anesthesia or epidural
  507  anesthesia.
  508         (11)(3) “Practice of osteopathic medicine” means the
  509  diagnosis, treatment, operation, or prescription for any human
  510  disease, pain, injury, deformity, or other physical or mental
  511  condition, which practice is based in part upon educational
  512  standards and requirements which emphasize the importance of the
  513  musculoskeletal structure and manipulative therapy in the
  514  maintenance and restoration of health.
  515         (12)“Spinal anesthesia” means anesthesia produced by the
  516  injection of an anesthetic agent into the subarachnoid space of
  517  the spinal cord.
  518         (13)“Surgeon” means a physician who performs surgery.
  519         (14)“Surgery” means any manual or operative procedure,
  520  including the use of lasers, performed upon the body of a living
  521  human being for the purposes of preserving health, diagnosing or
  522  curing disease, repairing injury, correcting deformity or
  523  defects, prolonging life, or relieving suffering or any elective
  524  procedure for aesthetic, reconstructive, or cosmetic purposes,
  525  including, but not limited to: incision or curettage of tissue
  526  or an organ; suture or other repair of tissue or organ,
  527  including a closed as well as an open reduction of a fracture;
  528  extraction of tissue including premature extraction of the
  529  products of conception from the uterus; insertion of natural or
  530  artificial implants; or an endoscopic procedure with use of
  531  local or general anesthetic.
  532         (10)(4) “Osteopathic physician” means a person who is
  533  licensed to practice osteopathic medicine in this state.
  534         (4)(5) “Doctor of Osteopathy” and “Doctor of Osteopathic
  535  Medicine,” when referring to degrees, shall be construed to be
  536  equivalent and equal degrees.
  537         Section 11. Subsection (2) of section 459.005, Florida
  538  Statutes, is amended and subsection (3) is added to that
  539  section, to read:
  540         459.005 Rulemaking authority.—
  541         (2) A physician who performs any liposuction procedure
  542  procedures in which more than 1,000 cubic centimeters of
  543  supernatant fat is removed, any Level II office surgery level 2
  544  procedures lasting more than 5 minutes, or any Level III office
  545  surgery and all level 3 surgical procedures in an office setting
  546  must register the office with the department unless that office
  547  is licensed as a facility under chapter 395. The department
  548  shall inspect the physician’s office annually unless the office
  549  is accredited by a nationally recognized accrediting agency or
  550  an accrediting organization subsequently approved by the Board
  551  of Osteopathic Medicine. The actual costs for registration and
  552  inspection or accreditation shall be paid by the person seeking
  553  to register and operate the office setting in which office
  554  surgery is performed. As a condition of registration, a
  555  physician who performs such surgical procedures in an office
  556  setting, and the office itself if it is a separate legal entity
  557  from the physician, must maintain the same levels of financial
  558  responsibility required in s. 459.0085.
  559         (3) The department may adopt rules to administer the
  560  registration, inspection, and safety of offices in which a
  561  physician performs office surgery. The board shall adopt by rule
  562  standards of practice for physicians who perform office surgery.
  563  The board shall impose a fine of $5,000 per day on a physician
  564  who performs a surgical procedure identified in subsection (2)
  565  in an office that is not registered with the department.
  566         Section 12. Paragraph (xx) is added to subsection (1) of
  567  section 459.015, Florida Statutes, to read:
  568         459.015 Grounds for disciplinary action; action by the
  569  board and department.—
  570         (1) The following acts constitute grounds for denial of a
  571  license or disciplinary action, as specified in s. 456.072(2):
  572         (xx) Performing a liposuction procedure in which more than
  573  1,000 cubic centimeters of supernatant fat is removed, a Level
  574  II office surgery, or a Level III office surgery in an office
  575  that is not registered with the department pursuant to s.
  576  459.005(2).
  577         Section 13. Paragraph (b) of subsection (4) of section
  578  464.012, Florida Statutes, is amended to read:
  579         464.012 Licensure of advanced practice registered nurses;
  580  fees; controlled substance prescribing.—
  581         (4) In addition to the general functions specified in
  582  subsection (3), an advanced practice registered nurse may
  583  perform the following acts within his or her specialty:
  584         (b) The certified registered nurse anesthetist may, to the
  585  extent authorized by established protocol approved by the
  586  medical staff of the facility in which the anesthetic service is
  587  performed, perform any or all of the following:
  588         1. Determine the health status of the patient as it relates
  589  to the risk factors and to the anesthetic management of the
  590  patient through the performance of the general functions.
  591         2. Based on history, physical assessment, and supplemental
  592  laboratory results, determine, with the consent of the
  593  responsible physician, the appropriate type of anesthesia within
  594  the framework of the protocol.
  595         3. Order under the protocol preanesthetic medication.
  596         4. Perform under the protocol procedures commonly used to
  597  render the patient insensible to pain during the performance of
  598  surgical, obstetrical, therapeutic, or diagnostic clinical
  599  procedures. These procedures include ordering and administering
  600  regional, spinal, and general anesthesia; inhalation agents and
  601  techniques; intravenous agents and techniques; and techniques of
  602  hypnosis.
  603         5. Order or perform monitoring procedures indicated as
  604  pertinent to the anesthetic health care management of the
  605  patient.
  606         6. Support life functions during anesthesia health care,
  607  including induction and intubation procedures, the use of
  608  appropriate mechanical supportive devices, and the management of
  609  fluid, electrolyte, and blood component balances.
  610         7. Recognize and take appropriate corrective action for
  611  abnormal patient responses to anesthesia, adjunctive medication,
  612  or other forms of therapy.
  613         8. Recognize and treat a cardiac arrhythmia while the
  614  patient is under anesthetic care.
  615         9. Participate in management of the patient while in the
  616  postanesthesia recovery area, including ordering the
  617  administration of fluids and drugs.
  618         10. Place special peripheral and central venous and
  619  arterial lines for blood sampling and monitoring as appropriate.
  620         11. Provide the services identified in subsections 1.-10.
  621  in an office registered to perform office surgery pursuant to s.
  622  458.309(3) or s. 459.005(2) within the framework of an
  623  established protocol with an anesthesiologist licensed under
  624  chapter 458 or chapter 459.
  625         Section 14. Paragraph (a) of subsection (1) of section
  626  766.101, Florida Statutes, is amended to read:
  627         766.101 Medical review committee, immunity from liability.—
  628         (1) As used in this section:
  629         (a) The term “medical review committee” or “committee”
  630  means:
  631         1.a. A committee of a hospital or ambulatory surgical
  632  center licensed under chapter 395 or a health maintenance
  633  organization certificated under part I of chapter 641;
  634         b. A committee of a physician-hospital organization, a
  635  provider-sponsored organization, or an integrated delivery
  636  system;
  637         c. A committee of a state or local professional society of
  638  health care providers;
  639         d. A committee of a medical staff of a licensed hospital or
  640  nursing home, provided the medical staff operates pursuant to
  641  written bylaws that have been approved by the governing board of
  642  the hospital or nursing home;
  643         e. A committee of the Department of Corrections or the
  644  Correctional Medical Authority as created under s. 945.602, or
  645  employees, agents, or consultants of either the department or
  646  the authority or both;
  647         f. A committee of a professional service corporation formed
  648  under chapter 621 or a corporation organized under part I of
  649  chapter 607 or chapter 617, which is formed and operated for the
  650  practice of medicine as defined in s. 458.305 s. 458.305(3), and
  651  which has at least 25 health care providers who routinely
  652  provide health care services directly to patients;
  653         g. A committee of the Department of Children and Families
  654  which includes employees, agents, or consultants to the
  655  department as deemed necessary to provide peer review,
  656  utilization review, and mortality review of treatment services
  657  provided pursuant to chapters 394, 397, and 916;
  658         h. A committee of a mental health treatment facility
  659  licensed under chapter 394 or a community mental health center
  660  as defined in s. 394.907, provided the quality assurance program
  661  operates pursuant to the guidelines that have been approved by
  662  the governing board of the agency;
  663         i. A committee of a substance abuse treatment and education
  664  prevention program licensed under chapter 397 provided the
  665  quality assurance program operates pursuant to the guidelines
  666  that have been approved by the governing board of the agency;
  667         j. A peer review or utilization review committee organized
  668  under chapter 440;
  669         k. A committee of the Department of Health, a county health
  670  department, healthy start coalition, or certified rural health
  671  network, when reviewing quality of care, or employees of these
  672  entities when reviewing mortality records; or
  673         l. A continuous quality improvement committee of a pharmacy
  674  licensed pursuant to chapter 465,
  675  
  676  which committee is formed to evaluate and improve the quality of
  677  health care rendered by providers of health service, to
  678  determine that health services rendered were professionally
  679  indicated or were performed in compliance with the applicable
  680  standard of care, or that the cost of health care rendered was
  681  considered reasonable by the providers of professional health
  682  services in the area; or
  683         2. A committee of an insurer, self-insurer, or joint
  684  underwriting association of medical malpractice insurance, or
  685  other persons conducting review under s. 766.106.
  686         Section 15. This act shall take effect upon becoming a law.