Florida Senate - 2019                                     SB 972
       By Senator Brandes
       24-00652A-19                                           2019972__
    1                        A bill to be entitled                      
    2         An act relating to innovation in the advanced practice
    3         registered nursing workforce; amending s. 464.003,
    4         F.S.; revising the definition of the term “advanced or
    5         specialized nursing practice” to expand the scope of
    6         practice; amending s. 464.012, F.S.; authorizing an
    7         advanced practice registered nurse to perform certain
    8         functions and acts within his or her specialty without
    9         a protocol agreement or supervision if specified
   10         requirements are met; creating s. 464.0125, F.S.;
   11         providing requirements for advanced practice
   12         registered nurses to practice without a protocol
   13         agreement or supervision; requiring the Department of
   14         Health to notify an advanced practice registered nurse
   15         who submits a satisfactory form that he or she is
   16         qualified to practice without a protocol agreement or
   17         supervision; requiring the department to update such
   18         practitioner’s profile; authorizing a qualified
   19         advanced practice registered nurse to admit, manage
   20         care for, and discharge certain patients and to
   21         provide an endorsement that is otherwise required to
   22         be provided by a physician; requiring the Board of
   23         Nursing to adopt a certain form by rule; providing
   24         construction; creating s. 464.0155, F.S.; requiring an
   25         advanced practice registered nurse practicing without
   26         a protocol agreement or supervision to report adverse
   27         incidents to the department; defining the term
   28         “adverse incident”; requiring a such report to be made
   29         in writing and sent by certified mail within a
   30         specified timeframe; requiring the department to
   31         review adverse incident reports to make a certain
   32         determination; authorizing the board to take
   33         disciplinary action against the advanced practice
   34         registered nurse if the department makes a certain
   35         determination; amending s. 395.0191, F.S.; conforming
   36         a provision to changes made by the act; providing an
   37         effective date.
   39  Be It Enacted by the Legislature of the State of Florida:
   41         Section 1. Subsection (2) of section 464.003, Florida
   42  Statutes, is amended to read:
   43         464.003 Definitions.—As used in this part, the term:
   44         (2) “Advanced or specialized nursing practice” means, in
   45  addition to the practice of professional nursing, the
   46  performance of advanced-level nursing acts approved by the board
   47  which, by virtue of postbasic specialized education, training,
   48  and experience, are appropriately performed by an advanced
   49  practice registered nurse. Within the context of advanced or
   50  specialized nursing practice, the advanced practice registered
   51  nurse may perform acts of nursing diagnosis and nursing
   52  treatment of alterations of the health status. The advanced
   53  practice registered nurse may also perform acts of medical
   54  diagnosis and treatment, prescription, and operation as
   55  authorized within the framework of an established supervisory
   56  protocol or without a protocol agreement or supervision pursuant
   57  to s. 464.0125. The department may, by rule, require that a copy
   58  of the protocol be filed with the department along with the
   59  notice required by s. 458.348.
   60         Section 2. Subsections (3) and (4) of section 464.012,
   61  Florida Statutes, are amended to read:
   62         464.012 Licensure of advanced practice registered nurses;
   63  fees; controlled substance prescribing.—
   64         (3) An advanced practice registered nurse shall perform
   65  those functions authorized in this section within the framework
   66  of an established protocol that must be maintained on site at
   67  the location or locations at which an advanced practice
   68  registered nurse practices and may practice without a protocol
   69  agreement or supervision pursuant to s. 464.0125. In the case of
   70  multiple supervising physicians in the same group, an advanced
   71  practice registered nurse must enter into a supervisory protocol
   72  with at least one physician within the physician group practice.
   73  A practitioner currently licensed under chapter 458, chapter
   74  459, or chapter 466 shall maintain supervision for directing the
   75  specific course of medical treatment. Within the established
   76  framework, or pursuant to s. 464.0125, an advanced practice
   77  registered nurse may:
   78         (a) Prescribe, dispense, administer, or order any drug;
   79  however, an advanced practice registered nurse may prescribe or
   80  dispense a controlled substance as defined in s. 893.03 only if
   81  the advanced practice registered nurse has graduated from a
   82  program leading to a master’s or doctoral degree in a clinical
   83  nursing specialty area with training in specialized practitioner
   84  skills.
   85         (b) Initiate appropriate therapies for certain conditions.
   86         (c) Perform additional functions as may be determined by
   87  rule in accordance with s. 464.003(2).
   88         (d) Order diagnostic tests and physical and occupational
   89  therapy.
   90         (e) Order any medication for administration to a patient in
   91  a facility licensed under chapter 395 or part II of chapter 400,
   92  notwithstanding any provisions in chapter 465 or chapter 893.
   93         (4) In addition to the general functions specified in
   94  subsection (3), an advanced practice registered nurse may
   95  perform the following acts within his or her specialty:
   96         (a) The certified nurse practitioner may perform any or all
   97  of the following acts within the framework of established
   98  protocol or pursuant to s. 464.0125:
   99         1. Manage selected medical problems.
  100         2. Order physical and occupational therapy.
  101         3. Initiate, monitor, or alter therapies for certain
  102  uncomplicated acute illnesses.
  103         4. Monitor and manage patients with stable chronic
  104  diseases.
  105         5. Establish behavioral problems and diagnosis and make
  106  treatment recommendations.
  107         (b) The certified registered nurse anesthetist may, to the
  108  extent authorized by established protocol approved by the
  109  medical staff of the facility in which the anesthetic service is
  110  performed, or pursuant to s. 464.0125, perform any or all of the
  111  following:
  112         1. Determine the health status of the patient as it relates
  113  to the risk factors and to the anesthetic management of the
  114  patient through the performance of the general functions.
  115         2. Based on history, physical assessment, and supplemental
  116  laboratory results, determine, with the consent of the
  117  responsible physician, the appropriate type of anesthesia within
  118  the framework of the protocol.
  119         3. Order under the protocol preanesthetic medication.
  120         4. Perform under the protocol procedures commonly used to
  121  render the patient insensible to pain during the performance of
  122  surgical, obstetrical, therapeutic, or diagnostic clinical
  123  procedures. These procedures include ordering and administering
  124  regional, spinal, and general anesthesia; inhalation agents and
  125  techniques; intravenous agents and techniques; and techniques of
  126  hypnosis.
  127         5. Order or perform monitoring procedures indicated as
  128  pertinent to the anesthetic health care management of the
  129  patient.
  130         6. Support life functions during anesthesia health care,
  131  including induction and intubation procedures, the use of
  132  appropriate mechanical supportive devices, and the management of
  133  fluid, electrolyte, and blood component balances.
  134         7. Recognize and take appropriate corrective action for
  135  abnormal patient responses to anesthesia, adjunctive medication,
  136  or other forms of therapy.
  137         8. Recognize and treat a cardiac arrhythmia while the
  138  patient is under anesthetic care.
  139         9. Participate in management of the patient while in the
  140  postanesthesia recovery area, including ordering the
  141  administration of fluids and drugs.
  142         10. Place special peripheral and central venous and
  143  arterial lines for blood sampling and monitoring as appropriate.
  144         (c) The certified nurse midwife may, to the extent
  145  authorized by an established protocol which has been approved by
  146  the medical staff of the health care facility in which the
  147  midwifery services are performed, or approved by the nurse
  148  midwife’s physician backup when the delivery is performed in a
  149  patient’s home, or pursuant to s. 464.0125, perform any or all
  150  of the following:
  151         1. Perform superficial minor surgical procedures.
  152         2. Manage the patient during labor and delivery to include
  153  amniotomy, episiotomy, and repair.
  154         3. Order, initiate, and perform appropriate anesthetic
  155  procedures.
  156         4. Perform postpartum examination.
  157         5. Order appropriate medications.
  158         6. Provide family-planning services and well-woman care.
  159         7. Manage the medical care of the normal obstetrical
  160  patient and the initial care of a newborn patient.
  161         (d) The clinical nurse specialist may perform any or all of
  162  the following acts within the framework of established protocol
  163  or pursuant to s. 464.0125:
  164         1. Assess the health status of individuals and families
  165  using methods appropriate to the population and area of
  166  practice.
  167         2. Diagnose human responses to actual or potential health
  168  problems.
  169         3. Plan for health promotion, disease prevention, and
  170  therapeutic intervention in collaboration with the patient or
  171  client.
  172         4. Implement therapeutic interventions based on the nurse
  173  specialist’s area of expertise and within the scope of advanced
  174  nursing practice, including, but not limited to, direct nursing
  175  care, counseling, teaching, and collaboration with other
  176  licensed health care providers.
  177         5. Coordinate health care as necessary and appropriate and
  178  evaluate with the patient or client the effectiveness of care.
  179         (e) A psychiatric nurse, who meets the requirements in s.
  180  394.455(35), within the framework of an established protocol
  181  with a psychiatrist, or pursuant to s. 464.0125, may prescribe
  182  psychotropic controlled substances for the treatment of mental
  183  disorders.
  184         Section 3. Section 464.0125, Florida Statutes, is created
  185  to read:
  186         464.0125 Requirements for advanced practice registered
  187  nurses practicing without a protocol agreement or supervision.—
  188         (1) To qualify to practice as an advanced practice
  189  registered nurse without a protocol agreement or supervision, an
  190  advanced practice registered nurse must:
  191         (a) Hold an unencumbered license issued under s. 464.012,
  192  or an unencumbered license to practice as an advanced practice
  193  registered nurse in in another state, jurisdiction, or territory
  194  of the United States;
  195         (b) Complete at least 2,000 clinical practice hours or
  196  clinical instructional hours within the immediately preceding 5
  197  year period while practicing as an advanced practice registered
  198  nurse; and
  199         (c) Submit a form to the board attesting that he or she
  200  meets the requirements in paragraphs (a) and (b).
  201         (2) Upon satisfactory receipt of such form, the department
  202  shall:
  203         (a) Notify the advanced practice registered nurse that he
  204  or she is qualified to practice without a protocol agreement or
  205  supervision pursuant to this section; and
  206         (b) Update the practitioner’s profile, as described in s.
  207  456.041, to reflect that the advanced practice registered nurse
  208  is qualified to practice without a protocol agreement or
  209  supervision pursuant to this section.
  210         (3) An advanced practice registered nurse qualified to
  211  practice without a protocol agreement or supervision may
  212  perform, without a protocol agreement or supervision, the
  213  functions authorized in s. 464.012(3), the acts within his or
  214  her specialty as described in s. 464.012(4), and any of the
  215  following:
  216         (a) For a patient being treated at a hospital, long-term
  217  care hospital, skilled nursing facility, hospice, or
  218  intermediate care facility for the developmentally disabled:
  219         1. Admit the patient to the facility;
  220         2. Manage the care that the patient receives in the
  221  facility; and
  222         3. Discharge the patient from the facility, unless
  223  prohibited by federal law or rule.
  224         (b) Provide a signature, certification, stamp,
  225  verification, affidavit, or other endorsement that is otherwise
  226  required to be provided by a physician.
  227         (4) The board shall adopt a form by rule to be used by
  228  advanced practice registered nurses attesting that they have
  229  satisfied the criteria in subsection (1) to practice without a
  230  protocol agreement or supervision.
  231         (5) This section does not prevent an advanced practice
  232  registered nurse who satisfies the eligibility requirements in
  233  subsection (1) of this section from electing to continue
  234  practicing under a protocol agreement as required by s.
  235  464.012(3).
  236         Section 4. Section 464.0155, Florida Statutes, is created
  237  to read:
  238         464.0155 Reports of adverse incidents by advanced practice
  239  registered nurses practicing without a protocol agreement or
  240  supervision.—
  241         (1) An advanced practice registered nurse practicing
  242  without a protocol agreement or supervision, pursuant to s.
  243  464.0125, shall report any adverse incident to the department.
  244         (2) For the purposes of this section, the term “adverse
  245  incident” means any of the following events that are reasonably
  246  attributable to the prescription of a controlled substance by an
  247  advanced practice registered nurse practicing pursuant to s.
  248  464.0125:
  249         (a) A condition that requires the transfer of a patient to
  250  a hospital licensed under chapter 395.
  251         (b) Permanent physical injury to a patient.
  252         (c) Death of a patient.
  253         (3) An adverse incident report must be in writing, sent to
  254  the department by certified mail, and postmarked within 15 days
  255  after the date on which the adverse incident occurs if the
  256  adverse incident occurs at the office of the advanced practice
  257  registered nurse. If the adverse incident occurs when the
  258  patient is not at the office of the advanced practice registered
  259  nurse, the report must be postmarked within 15 days after the
  260  date on which the advanced practice registered nurse discovers
  261  or reasonably should have discovered the occurrence of the
  262  adverse incident.
  263         (4) The department shall review each adverse incident and
  264  determine whether the advanced practice registered nurse caused
  265  the adverse incident. If the department determines that the
  266  advanced practice registered nurse caused the adverse incident,
  267  the board may take disciplinary action against the advance
  268  practice registered nurse in accordance with s. 456.073.
  269         Section 5. Paragraph (b) of subsection (2) of section
  270  395.0191, Florida Statutes, is amended to read:
  271         395.0191 Staff membership and clinical privileges.—
  272         (2)
  273         (b) An advanced practice registered nurse who is certified
  274  as a registered nurse anesthetist licensed under part I of
  275  chapter 464 shall administer anesthesia under the onsite medical
  276  direction of a professional licensed under chapter 458, chapter
  277  459, or chapter 466, and in accordance with an established
  278  protocol approved by the medical staff. The medical direction
  279  shall specifically address the needs of the individual patient.
  280  This paragraph does not apply to a certified registered nurse
  281  anesthetist licensed under part I of chapter 464 who is
  282  practicing without a protocol agreement or supervision pursuant
  283  to s. 464.0125.
  284         Section 6. This act shall take effect July 1, 2019.