House Bill hb0597

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    Florida House of Representatives - 2002                 HB 597

        By Representatives Lerner, Sobel, Ritter, Rich, Joyner,
    Peterman, Detert, Barreiro and Heyman





  1                      A bill to be entitled

  2         An act relating to children's medical services;

  3         providing legislative intent with respect to

  4         the licensure and regulation of facilities that

  5         provide care for medically fragile or

  6         technologically dependent children; providing

  7         definitions; providing requirements for the

  8         licensure of subacute pediatric prescribed

  9         extended alternative care centers; providing

10         for the licensing of such facilities by the

11         Agency for Health Care Administration;

12         providing for fees; providing requirements for

13         applicants for licensure; providing

14         requirements for a licensee in administering

15         and managing a SPPEAC center; requiring that

16         each center have an advisory board; providing

17         for membership on the advisory board; providing

18         requirements for the admission of a child to a

19         SPPEAC center; requiring each center to

20         maintain policies for child care; requiring

21         that a board-certified pediatrician serve as

22         the medical director of a center; providing

23         requirements for the nursing services provided

24         at a SPPEAC center; providing requirements for

25         the qualifications and experience of nursing

26         personnel; specifying the minimum

27         staff-to-child ratio for a center; providing

28         requirements for ancillary professional staff;

29         requiring that a SPPEAC center provide certain

30         educational services for children admitted to

31         the center; requiring inservice training for

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  1         center staff and family members of children

  2         admitted to the center; requiring that the

  3         center maintain certain medical records;

  4         requiring that a center have a committee to

  5         conduct reviews for quality assurance;

  6         providing requirements for dietary services

  7         provided at a center; providing requirements

  8         for the physical environment of a SPPEAC

  9         center; requiring that a center maintain

10         certain specified safety, medical, and

11         emergency equipment; providing requirements for

12         infection control; providing requirements for

13         transportation services provided by a center;

14         requiring that a center conform to certain

15         minimum emergency standards; providing an

16         effective date.

17

18  Be It Enacted by the Legislature of the State of Florida:

19

20         Section 1.  Purpose.--It is the intent of the

21  Legislature to provide for the licensure and regulation of

22  facilities that provide care for medically fragile or

23  technologically dependent children.

24         Section 2.  Definitions.--As used in this act, the

25  term:

26         (1)  "Advisory board" means a group of health care

27  professionals and at least one consumer approved by the SPPEAC

28  medical and nursing directors to serve each SPPEAC center to

29  review policies, procedures, and licensure requirements and to

30  provide consultation to the administrators of the center.

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  1         (2)  "Agency" means the Agency for Health Care

  2  Administration.

  3         (3)  "Basic services" includes, but is not limited to,

  4  development, implementation, and monitoring of a comprehensive

  5  plan of care, developed in conjunction with a child's parent

  6  or guardian, which specifies the medical, nursing,

  7  psychosocial, and developmental therapies required by the

  8  medically fragile or technologically dependent child served,

  9  as well as the caregiver-training needs of the child's parent

10  or guardian.

11         (4)  "Medical director" means a physician who is

12  licensed under chapter 458 or chapter 459, Florida Statutes,

13  who is certified by the American Board of Pediatrics or the

14  American Osteopathic Board of Pediatrics, and who serves as

15  the liaison between the SPPEAC and the medical community.

16         (5)  "Medical records" means the medical records

17  maintained by a SPPEAC center in accordance with accepted

18  professional standards and practices.

19         (6)  "Medically fragile or technologically dependent

20  child" means a child who, because of a medical condition,

21  requires continuous therapeutic interventions or skilled

22  nursing supervision that is prescribed by a licensed physician

23  or advanced registered nurse practitioner and administered by

24  or under the direct, onsite supervision of a licensed

25  registered nurse.

26         (7)  "Nursing director" means a registered nurse who is

27  licensed under chapter 464, Florida Statutes, and who is

28  responsible for providing continuous supervision of services

29  provided by a SPPEAC center and managing the daily operations

30  of the center.

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  1         (8)  "Owner" or "operator" means an individual who has

  2  general administrative charge of a SPPEAC center.

  3         (9)  "Plan of care" means the comprehensive plan for

  4  implementing the medical, nursing, psychosocial,

  5  developmental, and educational therapies provided by a SPPEAC

  6  center.

  7         (10)  "Premises" means the buildings, beds, and

  8  facilities located at the main address of the licensee.

  9         (11)  "Prescribing physician" or "prescribing advanced

10  registered nurse practitioner" means the physician licensed

11  under chapter 458 or chapter 459, Florida Statutes, or the

12  advanced registered nurse practitioner licensed under chapter

13  464, Florida Statutes, who signs the order admitting a child

14  to a SPPEAC.

15         (12)  "Primary physician" or "primary advanced

16  registered nurse practitioner" means the physician licensed

17  under chapter 458 or chapter 459, Florida Statutes, or the

18  licensed advanced registered nurse practitioner licensed under

19  chapter 464, Florida Statutes, who maintains overall

20  responsibility for a child's medical management and who is

21  available for consultation and collaboration with the staff of

22  the SPPEAC center.

23         (13)  "Quality assurance" means the mandatory program

24  that all SPPEAC centers must have to assure periodic review of

25  medical records at least annually and the determination of the

26  quality and appropriateness of care rendered by the center.

27         (14)  "Quality assurance committee" means a group of

28  health care professionals and at least one consumer approved

29  by the SPPEAC medical and nursing directors to serve each

30  SPPEAC center to review SPPEAC medical records and treatment

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  1  procedures to evaluate the quality of care provided to each

  2  child.

  3         (15)  "Subacute pediatric prescribed extended

  4  alternative care center" or "SPPEAC center" means any building

  5  or other place, whether operated for profit or not, which

  6  provides basic services to three or more medically fragile or

  7  technologically dependent children who are not related to the

  8  owner or operator by blood, marriage, or adoption and who

  9  require such services. Infants and children considered for

10  admission to a SPPEAC center must have a complex medical

11  condition that requires daily care, transitional care, or

12  continual care. The prerequisite for admission is a

13  prescription from the child's attending physician or advanced

14  registered nurse practitioner and consent of the child's

15  parent or guardian.

16         Section 3.  License required.--

17         (1)  A person, firm, association, partnership, or

18  corporation may not directly or indirectly operate a SPPEAC

19  center in this state without first applying for and receiving

20  a license from the agency to operate the facility.

21         (2)  Any person operating a facility in this state is

22  subject to the requirements of this act.

23         (3)  An applicant for licensure must submit a separate

24  application for each building of a facility if the buildings

25  are located on separate premises.

26         (4)  A licensee may not operate a facility at a

27  capacity greater than the number of clients indicated on the

28  face of the license.

29         (5)  A license issued for the operation of a SPPEAC

30  center expires 1 year following the date of issuance, unless

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  1  sooner suspended or revoked. An applicant for license renewal

  2  must comply with the provisions of this act.

  3         (6)  Another licensed entity may not collocate with a

  4  SPPEAC center.

  5         Section 4.  Licensure procedure.--

  6         (1)  Application for a license to operate a SPPEAC

  7  center must be made on a form prescribed by the agency and

  8  must be submitted to the agency under oath by the owner or

  9  administrator of the center.

10         (2)  Except for a county or municipality, each

11  applicant must submit a license fee of $650 to the Agency for

12  Health Care Administration, along with the application for

13  licensure.

14         (3)  All information provided on the application forms,

15  or by a request for additional information, must be accurate

16  and current at the time of filing.

17         (4)  For purposes of this section, with respect to

18  information required to be submitted to the agency by an

19  applicant for a license to operate a SPPEAC center which

20  concerns aspects, qualifications, or characteristics personal

21  to the applicant, including age, moral character, affiliation

22  through ownership or employment with other SPPEAC centers, and

23  the applicant's criminal record, the term "applicant" means

24  the individual applicant, if the applicant is an individual,

25  and the term "applicant" means all members of the board of

26  directors and all officers, if the applicant is a firm,

27  partnership, association, or corporation.

28         (5)  For purposes of this section, with respect to

29  information required to be submitted to the agency by an

30  applicant for a license to operate a SPPEAC center which

31  concerns qualifications or characteristics personal to the

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  1  administrator, manager, or supervisor, including age, moral

  2  character, affiliation through ownership or employment with

  3  other SPPEAC centers, and the applicant's criminal record, the

  4  terms "administrator," "manager," and "supervisor" include the

  5  manager, the supervisor, and all members of the board of

  6  directors and all officers of any firm, partnership,

  7  association, or corporation with which the applicant may

  8  contract to provide for the management or supervision of the

  9  SPPEAC center.

10         (6)  An applicant for an initial license to operate a

11  SPPEAC center shall submit an application providing all of the

12  information required by the agency, which must include:

13         (a)  The number of clients for which the license is

14  being requested.

15         (b)  The name of the SPPEAC center's administrator,

16  manager, or supervisor; the name and license number of the

17  director of nursing and all other currently employed licensed

18  personnel; and the number of currently employed supportive

19  personnel having responsibility for any part of the care given

20  to clients.

21         (c)  A listing of the number of dietary, housekeeping,

22  maintenance, and other personnel who are available on a daily

23  basis.

24         (d)  Certificates of approval from the local zoning

25  authority indicating that the location of the facility

26  conforms to local zoning ordinances.

27         (e)  Proof of financial ability to operate the facility

28  in accordance with the requirements of this act, which must be

29  documented as follows:

30         1.  A projection of revenue and expenses for the first

31  12 months of operation, including a conversion of the

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  1  projection to a cash-flow analysis, a balance sheet as of the

  2  beginning of the reporting period, and a pro forma balance

  3  sheet as of the end of the reporting period. These documents

  4  must be prepared in accordance with generally accepted

  5  accounting principles;

  6         2.  A copy of all deeds, contracts for sale, and

  7  leases, whether existing or proposed, showing that the

  8  applicant is responsible for the operation of the facility;

  9         3.  A contingency plan that demonstrates the ability of

10  the applicant to handle extraordinary occurrences that would

11  have a financial impact, such as major repairs, purchase of

12  capital equipment, or decrease in paid children's days. An

13  applicant meets this requirement if necessary contingency

14  funds are guaranteed from within the applicant's organization

15  or from proprietors, partners, or stockholders, or are

16  evidenced as available from commitments from lending

17  institutions, a line of credit, a letter of credit, or similar

18  evidence. If the contingency funds are guaranteed by the

19  applicant's organization, a proprietor, partners, or

20  stockholders, the guarantors must submit a signed statement

21  that the required funds shall be made available when

22  necessary. The applicant must have a positive cash flow,

23  including contingency funding, for each of the first 12 months

24  of operation and must have a contingency plan for an amount

25  not less than 80 percent of the total expenses detailed in the

26  operating budget for the first 12 months of operation. If a

27  line of credit exists, a letter from the lending institution

28  must be submitted which states:

29         a.  The amount;

30         b.  The terms and conditions;

31         c.  The interest rate;

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  1         d.  The repayment schedule;

  2         e.  The collateral;

  3         f.  The guarantors; and

  4         g.  The balance available on the date of license

  5  application;

  6         4.  The names of proprietors, partners, or stockholders

  7  owning at least a 10-percent interest, and the officers of:

  8         a.  The applicant;

  9         b.  The lessor;

10         c.  The management company; and

11         d.  The seller.

12

13  The financial information submitted by the applicant for

14  compliance with requirements for proof of financial ability

15  must be prepared in accordance with generally accepted

16  accounting principles. The financial information must be

17  reviewed by the agency, and a decision shall be made regarding

18  the applicant's financial ability to operate a SPPEAC center.

19  All financial statements, other then projections, must be

20  certified as true and correct by a corporate officer, all

21  partners of a partnership, or an individual delegated by the

22  owner to do so, as appropriate.

23         (f)  For new construction or new operations:

24         1.  Certificates of zoning approval from the county or

25  the municipality if the facility is located within municipal

26  limits; and

27         2.  Proof of approval for occupancy.

28         (g)  For a change of the licensed operator, proof of

29  compliance with applicable provisions of this act.

30         (h)  Any other additional information the agency finds

31  necessary in order to act upon the application.

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  1         (7)  An applicant for renewal of a license to operate a

  2  facility must submit an application that includes:

  3         (a)  All of the information required by paragraphs

  4  (6)(a), (d), (e), and (f); and

  5         (b)  The information required by paragraph (6)(b) for

  6  each of the new personnel, if there has been a change of

  7  administrator, manager, supervisor, medical director, director

  8  of nursing services, or any licensed nurse during the

  9  preceding year.

10         (8)  If the licensee of a facility seeks to increase

11  the number of children for which the facility is licensed, the

12  licensee must:

13         (a)  Provide certificates of approval from the local

14  zoning authority indicating that the location of the facility

15  conforms to local zoning ordinances as to capacity; and

16         (b)  Submit an application as required by subsection

17  (7) to modify the license accordingly.

18         (9)  Each applicant for a license to operate a

19  facility, whether for initial licensure or for renewal, and

20  the administrator, manager, or supervisor of the facility

21  must:

22         (a)  Be 18 years of age or older;

23         (b)  Be of good moral character; and

24         (c)  Have not been convicted or found guilty,

25  regardless of adjudication, in any jurisdiction, of any felony

26  involving fraud, embezzlement, fraudulent conversion,

27  misappropriation of property, violence against a person, or

28  moral turpitude.

29         (10)  Documentation for the agency showing compliance

30  with subsection (9), whether for initial licensure or for

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  1  renewal, must be submitted with the application and must

  2  include:

  3         (a)  Three character references for the applicant and

  4  for the administrator, manager, or supervisor of the facility,

  5  except on renewal if previously provided to the department;

  6         (b)  The criminal record, if any, for the applicant and

  7  for the administrator, manager, or supervisor of the facility,

  8  listing the court, the date of conviction, the offense, and

  9  the penalty imposed for each conviction regardless of

10  adjudication; and

11         (c)  A copy of any injunctive or restrictive order or

12  federal or state administrative order relating to business

13  activity or health care services as a result of an action

14  brought by a public agency or department, including, without

15  limitation, an action affecting a licensee under chapter 391,

16  Florida Statutes, which is currently in effect with respect to

17  the applicant or the administrator, manager, or supervisor of

18  the facility.

19         (11)(a)  Each facility must obtain and keep in force

20  liability insurance. Proof of liability insurance must be

21  submitted at the time of application. Liability insurance is

22  insurance against legal liability for death, injury, or

23  disability of any human being, or for damage to property, with

24  provision for medical, hospital, and surgical benefits to the

25  injured person, irrespective of the legal disability of the

26  insured, when issued as a part of a liability insurance

27  contract.

28         (b)  Minimum liability insurance coverage shall be at

29  least $50,000 per child for bodily injury and $150,000 per

30  occurrence for the center, and $50,000 per child for the

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  1  bodily injury and $150,000 per occurrence for the vehicles if

  2  transportation services are provided by the center.

  3         Section 5.  Administration and management.--

  4         (1)  The licensee of each SPPEAC center has full legal

  5  authority and responsibility for operating the facility.

  6  Responsibilities of the licensee include, but are not limited

  7  to:

  8         (a)  Employing or otherwise arranging for the services

  9  of personnel required to properly staff the center in

10  accordance with chapter 391, Florida Statutes, and this act;

11         (b)  Adopting and making public a statement of the

12  children's rights in accordance with chapter 391, Florida

13  Statutes;

14         (c)  Making application for a license to operate the

15  center in accordance with chapter 391, Florida Statutes, and

16  this act;

17         (d)  Providing equipment and supplies required to meet

18  the needs of the children;

19         (e)  Ensuring that the center is operated in compliance

20  with chapter 391, Florida Statutes, and this act;

21         (f)  Ensuring that services identified as required to

22  meet the needs of the children are provided directly by center

23  personnel or secured from outside sources; and

24         (g)  Ensuring that a copy of chapter 391, Florida

25  Statutes, a copy of rules 59A-13 and 10D-13, Florida

26  Administrative Code, a medical dictionary, the current year's

27  copy of the American Academy of Pediatrics Red Book, and the

28  current year's drug reference book are available in the

29  center.

30         (2)  The licensee shall manage the center on a sound

31  financial basis and shall have the financial ability to

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  1  operate the facility in accordance with the requirements of

  2  chapter 391, Florida Statutes, and this act. A violation of

  3  this standard includes issuing bad checks; failing to make

  4  timely tax and payroll deposits; or failing to meet financial

  5  obligations for food, shelter, care, and utilities when due.

  6         (3)  Each SPPEAC center shall be organized in

  7  accordance with a written table of organization which

  8  describes the lines of authority and communication down to the

  9  child-care level. The organizational structure must be

10  designed to ensure an integrated continuum of services to the

11  clients.

12         (4)(a)  The licensee of each center shall designate one

13  person as administrator who is responsible and accountable for

14  the overall management of the center.

15         (b)  The center administrator shall designate, in

16  writing or per organizational chart, a person who is

17  responsible for operating the center when the administrator is

18  absent from the center for 24 hours or longer.

19         (c)  Responsibilities of the center administrator

20  include, but are not limited to:

21         1.  Maintaining or causing to be maintained the

22  following written records and any other records required by

23  chapter 391, Florida Statutes, and this act, which records

24  must be kept in a place, form, and system ordinarily employed

25  in acceptable medical and business practices and must be

26  available in the center for inspection by the agency during

27  normal business hours:

28         a.  A census record that indicates the number of

29  children currently receiving services in the center;

30         b.  A record of all accidents or unusual incidents

31  involving any child or staff member which caused, or had the

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  1  potential to cause, injury or harm to any person or property

  2  within the center. Such records must contain a clear

  3  description of each accident or incident, the names of the

  4  persons involved, a description of all medical or other

  5  services provided to these persons, who provided such

  6  services, and the steps taken, if any, to prevent recurrence

  7  of such accident or incidents in the future;

  8         c.  A copy of current agreements with third-party

  9  providers;

10         d.  A copy of current agreements with each consultant

11  employed by the center and documentation of each consultant's

12  visits and required written, dated reports;

13         e.  A personnel record for each employee, including the

14  employee's current license or certificate number, as

15  applicable; the original employment application and references

16  furnished from the most recent health care employer and

17  employment history for the preceding 5 years; and a copy of

18  all job performance evaluations; and

19         f.  Fiscal records in accordance with subsection (5).

20         2.  Ensuring the development and maintenance of a

21  current job description for each employee.

22         3.  Ensuring that each employee is furnished with a

23  copy of written personnel policies governing conditions of

24  employment, including the job description for the employee's

25  own position.

26         4.  Ensuring that each employee receives at least a

27  yearly written job-performance evaluation that is discussed

28  with the employee, notes job performance strengths and

29  weaknesses, and discusses plans to correct any weaknesses in

30  job performance.

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  1         5.  Ensuring that each employee is assigned duties that

  2  are consistent with the employee's job description and with

  3  the employee's level of education, preparation, and

  4  experience.

  5         (5)(a)  The licensee for each SPPEAC center shall

  6  maintain fiscal records in accordance with the requirements of

  7  chapter 391, Florida Statutes, and this act.

  8         (b)  Each center shall use an accrual or cash system of

  9  accounting which reflects transactions of the business.

10  Records and accounts of transactions, general ledgers, or

11  disbursement journals must be posted at least quarterly and

12  must be available for review by the agency.

13         Section 6.  Advisory board.--

14         (1)  Each SPPEAC center must have an advisory board.

15  Membership on the advisory board must include, but need not be

16  limited to:

17         (a)  A physician or an advanced registered nurse

18  practitioner who is familiar with SPPEAC services;

19         (b)  A registered nurse who has experience in the care

20  of medically fragile or technologically dependent children;

21         (c)  A developmentalist or child life specialist who

22  has experience in the care of medically fragile or

23  technologically dependent children and their families;

24         (d)  A social worker who has experience in the care of

25  medically fragile or technologically dependent children and

26  their families; and

27         (e)  A consumer representative who is a parent or

28  guardian of a child placed in the SPPEAC center.

29         (2)  The advisory board shall:

30

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  1         (a)  Review the policy and procedure components of the

  2  SPPEAC center to assure conformance with the standards for

  3  licensure; and

  4         (b)  Provide consultation with respect to the

  5  operational and programmatic components of the SPPEAC center.

  6         Section 7.  Admission, transfer, and discharge

  7  policies.--

  8         (1)  Each SPPEAC center must have written policies and

  9  procedures governing the admission, transfer, and discharge of

10  children.

11         (2)  The admission of each child to a SPPEAC center

12  must be under the supervision of the center nursing

13  administrator or his or her designee, and must be in

14  accordance with the center's policies and procedures.

15         (3)  Each child admitted to a SPPEAC center shall be

16  admitted upon prescription of a prescribing physician or

17  advanced registered nurse practitioner and the child shall

18  remain under the care of the licensed primary physician or

19  advanced registered nurse practitioner for the duration of his

20  or her stay in the center.

21         (4)  Each child admitted to a SPPEAC center must meet

22  at least the following criteria:

23         (a)  The child must be medically fragile or

24  technologically dependent.

25         (b)  The child may not, prior to admission, present

26  significant risk of infection to other children or personnel.

27  The medical and nursing directors shall review, on a

28  case-by-case basis, any child who is suspected of having an

29  infectious disease to determine whether admission is

30  appropriate.

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  1         (c)  The child must be medically stabilized and require

  2  skilled nursing care or other interventions.

  3         (5)  If the child meets the criteria specified in

  4  paragraphs (4)(a), (b), and (c), the medical director or

  5  nursing director of the SPPEAC center shall implement a

  6  preadmission plan that delineates services to be provided and

  7  appropriate sources for such services.

  8         (a)  If the child is hospitalized at the time of

  9  referral, preadmission planning must include the participation

10  of the child's parent or guardian and relevant medical,

11  nursing, social services, and developmental staff to assure

12  that the hospital's discharge plans will be implemented

13  following the child's placement in the SPPEAC center.

14         (b)  A consent form, outlining the purpose of a SPPEAC

15  center, family responsibilities, authorized treatment,

16  appropriate release of liability, and emergency disposition

17  plans must be signed by the parent or guardian and witnessed

18  before the child is admitted to a SPPEAC center. The parent or

19  guardian shall be provided a copy of the consent form.

20  Confidentiality of SPPEAC records shall be maintained in

21  accordance with section 456.057, Florida Statutes.

22         Section 8.  Child care policies.--

23         (1)  Each SPPEAC center shall develop, implement, and

24  maintain written policies and procedures governing all child

25  care and related medical services or other services provided.

26         (2)  A group of professional staff from the SPPEAC

27  center shall develop and maintain child care policies and

28  procedures. The group shall include the medical director or

29  medical consultant, the center administrator, and the director

30  of nursing services. All child care policies and procedures

31  must be reviewed annually and revised as needed.

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  1         (3)  The child care policies and procedures developed

  2  shall, at a minimum, ensure client care in compliance with

  3  chapter 391, Florida Statutes, and the standards contained in

  4  this act.

  5         Section 9.  Medical director.--A board-certified

  6  pediatrician shall serve as the medical director for a SPPEAC

  7  center. Responsibilities of the medical director include:

  8         (1)  Periodically reviewing services in order to assure

  9  acceptable levels of quality;

10         (2)  Maintaining a liaison with the medical community;

11         (3)  Advising center personnel of the development of

12  new programs and modifications of existing programs;

13         (4)  Ensuring that medical consultation will be

14  available in the event of the medical director's absence;

15         (5)  Serving on committees as defined and required by

16  the center's policies;

17         (6)  Consulting with the center administrator on the

18  health status of facility personnel;

19         (7)  Reviewing reports of all accidents or unusual

20  incidents occurring on the premises and identifying to the

21  center administrator hazards to health and safety; and

22         (8)  Ensuring the development of a policy and procedure

23  for delivering emergency services and regular services when a

24  child's attending physician, advanced registered nurse

25  practitioner, or designated alternate is not available.

26         Section 10.  Nursing services.--

27         (1)  A registered nurse shall serve full-time as the

28  director of nursing at each SPPEAC center. The director of

29  nursing must:

30         (a)  Hold a baccalaureate degree in nursing;

31         (b)  Be licensed in this state as a registered nurse;

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  1         (c)  Have successfully completed a certification course

  2  in pediatric basic cardiac life support and advanced cardiac

  3  life support, with biennial recertification; and

  4         (d)  Have at least 2 years of experience in general

  5  pediatric care, including at least 6 months of experience in

  6  pediatric acute care during the previous 5 years.

  7         (2)  The director of nursing is responsible for the

  8  daily operation of the SPPEAC center, including:

  9         (a)  Ensuring that qualified personnel and ancillary

10  services are available as necessary to assure the health,

11  safety, and proper care of children; and

12         (b)  Ensuring that policies and procedures to control

13  infection are included in the center's policy manual.

14         (3)(a)  Each SPPEAC center must have a minimum of one

15  full-time equivalent registered nurse and one full-time

16  equivalent licensed practical nurse on site at all times.

17         (b)  The registered nurse must:

18         1.  Hold a baccalaureate degree in nursing;

19         2.  Be licensed in this state as a registered nurse;

20         3.  Have at least 2 years of experience in pediatric

21  specialty care;

22         4.  Receive biennial certification in pediatric basic

23  cardiac life support and pediatric advanced life support; and

24         5.  Have at least 2 years of experience in general

25  pediatrics, including at least 6 months of experience caring

26  for medically fragile or technologically dependent children.

27         (c)  A licensed practical nurse must:

28         1.  Be licensed in this state as a licensed practical

29  nurse;

30

31

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  1         2.  Have at least 2 years of experience in pediatric

  2  nursing, including experience in caring for acutely ill or

  3  chronically ill children within the previous 24 months;

  4         3.  Receive biennial certification in pediatric basic

  5  cardiac life support and pediatric advance life support; and

  6         4.  Have at least 2 years of experience in general

  7  pediatrics, including at least 6 months of experience caring

  8  for medically fragile or technologically dependent children.

  9         (d)  The registered nurses and licensed practical

10  nurses of a SPPEAC center are responsible for:

11         1.  Providing nursing interventions, providing

12  educational services to increase the family's confidence and

13  competence in caring for the child with special needs,

14  providing assistance to facilitate coping with the effects of

15  chronic illness on the child and family, supporting effective

16  relationships among siblings and the ill child, and providing

17  interventions to foster normal development and psychosocial

18  adaptation;

19         2.  Possessing a knowledge of the availability of and

20  requirements for accessing community resources; and

21         3.  Fostering and maintaining a collaborative

22  relationship with the interdisciplinary health team.

23         (4)(a)  If nursing assistants are used to augment

24  licensed nurse staff, each nursing assistant must:

25         1.  Be certified as a nurse assistant;

26         2.  Have a minimum of 2 years of experience in caring

27  for infants and toddlers;

28         3.  Provide references documenting his or her skill in

29  caring for infants and children; and

30         4.  Receive annual certification in basic cardiac life

31  support.

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  1         (b)  Each nursing assistant must work under the

  2  supervision of a licensed nurse and may provide direct care to

  3  children in the SPPEAC center.

  4         (5)  Total staffing for nursing services shall be, at a

  5  minimum, in the following ratios, but at least two staff

  6  members, including at least one registered nurse, must be on

  7  duty at all times and at least one staff member per three

  8  children must be on duty at all times:

  9         (a)  One to three children - one registered nurse and

10  one other.

11         (b)  Four to six children - one registered nurse and

12  two others.

13         (c)  Seven to nine children - one registered nurse, one

14  licensed practical nurse, and one other.

15         (d)  Ten to 12 children - two registered nurses, and

16  two others; or one registered nurse, two licensed practical

17  nurses, and one other.

18         (e)  Thirteen to 15 children - two registered nurses,

19  one licensed practical nurse, and two others.

20         (f)  Sixteen to 18 children - two registered nurses,

21  two licensed practical nurses, and two others.

22         (g)  Nineteen to 21 children - two registered nurses,

23  three licensed practical nurses, and two others.

24         (h)  Twenty-two to 24 children - two registered nurses,

25  three licensed practical nurses, and three others.

26         (i)  Twenty-five to 28 children - three registered

27  nurses, three licensed practical nurses, and three others.

28         Section 11.  Ancillary professional staffing

29  standards.--Each SPPEAC center shall have available on at

30  least a consultant basis:

31         (1)  A child development specialist who shall:

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  1         (a)  Serve as a resource for SPPEAC center staff and

  2  parents of children served; and

  3         (b)  Evaluate the developmental status of children

  4  using standardized and nonstandardized procedures.

  5         (2)  A child life specialist who has a baccalaureate

  6  degree in child life, early childhood education, or a related

  7  field, and at least 1 year of experience in planning and

  8  implementing developmental stimulation programs for children.

  9  The child life specialist shall:

10         (a)  Plan and conduct individualized child development

11  and play programs; and

12         (b)  Serve as a resource for SPPEAC center staff and

13  parents of children served.

14         (3)  An occupational therapist who is licensed under

15  chapter 468, Florida Statutes, is registered with the American

16  Occupational Therapy Association, and has at least 1 year of

17  experience in evaluating and planning treatment for children

18  with neuromuscular and developmental needs. The occupational

19  therapist shall:

20         (a)  Evaluate a child following referral by a physician

21  or advanced registered nurse practitioner to determine

22  neuromuscular status, developmental level, perceptual motor

23  functioning, need for adaptive equipment or appliances,

24  abilities for self-care, and the plan of care;

25         (b)  Design and implement a therapeutic program to meet

26  the needs of each individual child;

27         (c)  Maintain records documenting a child's therapy

28  program and progress; and

29         (d)  Serve as a resource for SPPEAC center staff.

30         (4)  A physical therapist who is licensed under chapter

31  468, Florida Statutes, is a graduate of a program approved by

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  1  the American Physical Therapy Association, and has at least 1

  2  year of experience in evaluating and designing therapeutic

  3  programs for children with developmental disabilities. The

  4  physical therapist shall:

  5         (a)  Evaluate a child referred by a physician or

  6  advanced registered nurse practitioner to determine the

  7  child's neuromuscular status, including the child's

  8  developmental level, gait, posture, and necessary adaptive

  9  equipment;

10         (b)  Design and implement a therapeutic program to meet

11  the needs of each individual child;

12         (c)  Maintain records documenting a child's therapy

13  program and progress, as approved by the attending physician

14  or advanced registered nurse practitioner; and

15         (d)  Serve as a resource for SPPEAC center staff and

16  parents of children served.

17         (5)  A speech pathologist who is certified by the

18  American Speech, Hearing, and Language Association and has at

19  least 1 year of experience in evaluating and treating children

20  at risk for, or experiencing problems with, communications

21  skills. The speech pathologist shall:

22         (a)  Perform evaluations, including evaluation of a

23  child's prespeech, feeding, respiration, language, speech,

24  communication, and play, using formal and informal tests and

25  observations;

26         (b)  Design and implement individualized therapeutic

27  programs for each child, including recommendations for

28  communication devices;

29         (c)  Maintain records documenting the child's therapy

30  programs and progress; and

31

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  1         (d)  Serve as a resource for SPPEAC center staff and

  2  parents of children served.

  3         (6)  A respiratory therapist who shall:

  4         (a)  Evaluate a child following referral by a physician

  5  or advanced registered nurse practitioner, including an

  6  evaluation of the child's respiratory condition;

  7         (b)  Perform diagnostic monitoring;

  8         (c)  Deliver aerosolized medications, bronchial hygiene

  9  therapy, chest physiotherapy, pulmonary lung-expansion

10  therapy, and oxygen therapy;

11         (d)  Monitor ventilator-dependent children;

12         (e)  Maintain records documenting a child's therapy

13  programs and progress; and

14         (f)  Serve as a resource for SPPEAC center staff and

15  parents of children served.

16         (7)  A social worker who is licensed under chapter 490

17  or chapter 491, Florida Statutes; holds a master's degree in

18  social work; and has at least 1 year of experience in

19  assessing, counseling, and planning interventions for children

20  and their families or guardians. The social worker shall:

21         (a)  Conduct family psychosocial assessments, as

22  requested by the medical or nursing director;

23         (b)  Provide counseling, including emotional support

24  and grief resolution, as requested by the medical or nursing

25  director or family;

26         (c)  Perform family advocacy and coordinate SPPEAC

27  services with community resources;

28         (d)  Maintain records documenting social-work

29  intervention;

30         (e)  Conduct home visits and home evaluations, as

31  requested by the medical director or nursing director; and

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  1         (f)  Serve as a resource for SPPEAC center staff and

  2  parents of children served.

  3         (8)  A licensed psychologist who has a doctoral degree

  4  in child-development counseling, psychology, or a related

  5  field and at least 1 year of experience in evaluating and

  6  managing children. The licensed psychologist must be available

  7  to the center as a consultant.

  8         (9)  A dietitian who is registered with the American

  9  Dietetic Association. The dietitian must be available to the

10  center as a consultant.

11         Section 12.  Educational services.--Each SPPEAC center

12  shall develop a cooperative program with the local school

13  system to provide a planned educational program, appropriate

14  to meet the needs of the individual child, or to provide a

15  board-certified instructor and planned educational program,

16  appropriate to meet the needs of the individual child.

17         Section 13.  Inservice training for all caregivers.--

18         (1)  Each SPPEAC center shall develop a comprehensive

19  training program that is available to all caregivers and

20  includes:

21         (a)  Inservice training for all family members; and

22         (b)  Quarterly staff-development programs, appropriate

23  to the category of personnel for which the programs are

24  conducted, for the purpose of maintaining quality patient

25  care.

26         (2)  All staff-development programs must be documented.

27         (3)  Each new employee must participate in orientation

28  to acquaint the employee with the philosophy, organization,

29  program, practices, and goals of the SPPEAC center.

30         (4)  At the time of the child's placement in the SPPEAC

31  center, the center shall provide a comprehensive orientation

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  1  to acquaint all family members with the philosophy and

  2  services of the center.

  3         Section 14.  Medical records.--A medical record shall

  4  be maintained for each child. The medical records must

  5  contain:

  6         (1)  All details of the referral, admission,

  7  correspondence, and papers concerning the child. Entries in

  8  the medical record must be in ink and signed by authorized

  9  personnel and include:

10         (a)  Orders of the physician or advanced registered

11  nurse practitioner;

12         (b)  Flow chart of medications and treatments

13  administered;

14         (c)  Concise, accurate information and initialed case

15  notes reflecting progress toward plan-of-care goals and the

16  child's progress or reasons for lack of progress;

17         (d)  Documentation of nutritional management and

18  special diets, as appropriate; and

19         (e)  Documentation of physical, occupational, speech,

20  and other special therapies.

21         (2)  An individualized plan of care developed within 10

22  working days after admission and revised to include

23  recommended changes in the therapeutic plans. The disposition

24  to be followed in the event of emergency situations must be

25  specified in the plan of care.

26         (3)  The medical history, including allergies and

27  special precautions.

28         (4)  The immunization record.

29         (5)  The quarterly review of the plan of care, which is

30  performed in consultation with other professionals involved in

31  the child's care.

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  1         (6)  A discharge order written by the primary physician

  2  or advanced registered nurse practitioner. The discharge order

  3  must be documented and entered in the child's record. A

  4  discharge summary that includes the reason for discharge must

  5  also be included.

  6         Section 15.  Quality assurance committee.--All SPPEAC

  7  centers must have a quality assurance program and conduct

  8  quarterly reviews of the SPPEAC center's medical records for

  9  at least half of the children served by the SPPEAC center at

10  the time of the review.

11         (1)  The quality assurance review shall be conducted by

12  two members of the quality assurance committee. The

13  responsibilities for conducting quality assurance review shall

14  rotate among the members of the quality assurance committee

15  members at least annually. Within 15 working days after its

16  review, the quality assurance committee shall furnish copies

17  of its report to the medical and nursing directors of the

18  SPPEAC center.

19         (2)(a)  Each quarterly quality assurance review must

20  include:

21         1.  A review of the goals in each child's plan of care;

22         2.  A review of the steps, process, and success in

23  achieving the goals; and

24         3.  Identification of goals not being achieved as

25  expected, reasons for lack of achievement, and plans to

26  promote achievement of goals.

27         (b)  Evidence that the plan of care has been revised to

28  accommodate the findings of a quality assurance report shall

29  be forwarded to the quality assurance committee within 10

30  working days after receipt of the report by the quality

31  assurance committee.

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  1         (c)  Implementation of the revisions to the plan of

  2  care must be documented on the child's medical record.

  3         (3)  The quality assurance committee shall also

  4  ascertain the presence of the following documents in each

  5  child's medical record:

  6         (a)  A properly executed consent form;

  7         (b)  A medical history for the child, including

  8  notations from visits to health care providers; and

  9         (c)  Immunization records, documentation of allergies,

10  and special precautions.

11         Section 16.  Dietary services.--A registered dietitian

12  shall be available for consultation regarding the nutritional

13  needs and special diets of individual children. If food is

14  prepared on site, the center is subject to routine inspections

15  by the Department of Health and must conform to food service

16  standards for child care facilities adopted by the Department

17  of Health.

18         Section 17.  Physical environment.--The SPPEAC center's

19  physical location and building must comply with at least the

20  following minimum requirements:

21         (1)  Each facility licensed as a SPPEAC center must be

22  able to accommodate at least three medically fragile or

23  technologically dependent children.

24         (2)  Specifications for a SPPEAC center include:

25         (a)  Compliance with part V of chapter 553, Florida

26  Statutes, for accessibility of public buildings for

27  handicapped persons; and

28         (b)  Adequate parking for staff and families to comply

29  with applicable local zoning requirements.

30         (3)  Requirements for building space allocation

31  include:

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  1         (a)  An isolation room with anteroom, a private

  2  bathroom with shower or raised tub, and an individual

  3  air-conditioning and heating unit.

  4         (b)  A dining area large enough to accommodate at least

  5  two-thirds of facility population at one time.

  6         (c)  A kitchen area that includes standard kitchen

  7  equipment of stove, oven, refrigerator, dishwasher, and double

  8  sink with disposal.

  9         (d)  An indoor play area, including accommodations for

10  mobile and nonmobile children.

11         (e)  An outdoor play area, fenced and free of safety

12  hazards, with appropriate playground equipment and toys.

13         (f)  Sleep rooms that comply with the following

14  requirements:

15         1.  One appropriate bed or crib assigned per child;

16         2.  A maximum of three children assigned to each sleep

17  room;

18         3.  A minimum of 28 square feet per child;

19         4.  Hanging closet space with drawers;

20         5.  Direct access to a bathroom with shower or standard

21  tub;

22         6.  A changing area with sink; and

23         7.  Adequate seating with a minimum of one chair per

24  child.

25         (g)  A laundry room with washer and dryer or daily

26  linen service.

27         (h)  A business office.

28         (i)  A children's bathroom in the common area which has

29  one toilet, one basin, and one standard bathtub or shower.

30         (j)  An adult bathroom that has one toilet and one

31  basin.

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  1         (k)  A staff lounge that includes:

  2         1.  A bathroom, with one toilet, one basin, and one

  3  shower stall with private changing area per 15 staff members;

  4         2.  Couches or seating to accommodate a minimum of

  5  one-fourth of the staff at any time; and

  6         3.  Secure lockers for personal items.

  7         (l)  A nurses station and medication area that includes

  8  a locked cabinet and emergency kit.

  9         (m)  An education room, including one area designated

10  for children 0-2 years of age.

11         (n)  A gymnasium area for therapies, with a minimum of

12  one private speech room.

13         Section 18.  Furniture and linens.--Each SPPEAC center

14  must provide an appropriate mix of cribs, beds, highchairs,

15  infant seats, and changing tables to meet the needs of the

16  children being served. All provided items must be maintained

17  in a safe and sanitary condition. A minimum of one bed or crib

18  per child is required, which may not be occupied by more than

19  one child at a time. Linens must be changed and mattresses

20  sanitized before use by another child.

21         Section 19.  Equipment.--Each SPPEAC center shall

22  provide safety, medical, and emergency equipment as described

23  in this section. All equipment must be maintained in a safe,

24  usable, and sanitary condition.

25         (1)  The following items of safety equipment must be

26  available on the premises:

27         (a)  Extinguishers, alarms, and smoke detectors, as

28  required by the Life Safety Code, NFPA-101, 1985 edition;

29         (b)  Circuit interrupters;

30         (c)  Flush door openers;

31

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  1         (d)  Child-proof safety latches on closets and

  2  cabinets;

  3         (e)  Straps on all highchairs, swings, and infant

  4  seats;

  5         (f)  Locks on specific storage cabinets;

  6         (g)  Bumper pads on infant cribs; and

  7         (h)  Covers for electric outlets.

  8         (2)  The following items of medical equipment must be

  9  available on the premises:

10         (a)  Suction machines - one per child requiring daily

11  suctioning, plus one suction machine for emergency use;

12         (b)  Mist tents - one per child with respiratory

13  diagnosis as prescribed;

14         (c)  Lockable narcotics cabinet;

15         (d)  Mechanical percussors and hand percussors as

16  prescribed;

17         (e)  Oxygen in two portable tanks, or piped in with

18  appropriate tubing, pediatric manual resuscitation, and masks

19  for faces and tracheostomies;

20         (f)  Ventilator with provision for mixing gases to

21  provide prescribed oxygen concentration as specifically

22  prescribed or to be used as a backup unit when a

23  ventilator-dependent child is in the center;

24         (g)  Thermometers, excluding glass thermometers;

25         (h)  Sphygmomanometers, stethoscopes, osteoscopes, and

26  ophthalmoscopes;

27         (i)  Apnea-monitoring supplies, including belts and

28  leads to apply to monitors brought from home; and

29         (j)  Supplies of disposable equipment as needed.

30         (3)  The following items of emergency equipment and

31  supplies must be available on the premises:

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  1         (a)  An emergency power-generator system, with adequate

  2  generating power to maintain medical equipment in the center

  3  in case of power failure.

  4         (b)  Basic emergency equipment, including:

  5         1.  Airways, in a range of appropriate pediatric sizes;

  6         2.  Suction catheters, in a range of appropriate

  7  pediatric sizes;

  8         3.  Pediatric manual resuscitator, self-inflating, with

  9  premature infant, infant, and pediatric masks;

10         4.  Infant oxygen masks;

11         5.  Child oxygen masks;

12         6.  Oxygen regulator with mist bottle and heating

13  element;

14         7.  Flashlight with extra batteries in each room;

15         8.  Stethoscope;

16         9.  Feeding tubes in a range of appropriate pediatric

17  sizes;

18         10.  Disposable plastic syringes and needles in a range

19  of appropriate pediatric sizes;

20         11.  Intravenous catheter, angiocatheter, and scalp

21  vein needles in a range of appropriate pediatric sizes;

22         12.  Tourniquets; armboards in premature infant,

23  infant, and child sizes; and adhesive tape of various sizes;

24         13.  Two-way stopcocks;

25         14.  One electrical-outlet adapter for three-prong

26  outlets; and

27         15.  Antiseptic preps and alcohol preps.

28         (c)  Basic drugs and solutions, including:

29         1.  Epinephrine ampules, two each of 1:1,000 and

30  1:10,000;

31

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  1         2.  Dextrose in 25-percent solution and 50-percent

  2  solution;

  3         3.  Ipecac, one 30cc bottle;

  4         4.  Sterile water, two vials;

  5         5.  Normal saline, two vials;

  6         6.  Dextrose 5 percent in water, one 500cc bag; and

  7         7.  Dextrose 5 percent in Lactated Ringer's, two 500cc

  8  bags;

  9         (d)  If tank oxygen is used, two portable cylinders of

10  oxygen, properly secured.

11         (e)  A suction machine with sterile suction catheters

12  in pediatric sizes.

13         (4)  Emergency equipment must be checked daily for

14  expiration, contamination, or damage, and a log must be

15  maintained and signed every day by the nurse responsible for

16  verifying the examining of emergency equipment.

17         Section 20.  Infection control.--

18         (1)  Each SPPEAC center must have an isolation room

19  with one large glass area for observing the child.

20         (2)  Isolation procedures must be used to prevent

21  cross-infections.

22         (3)  All cribs and beds must be labeled with the

23  individual child's name. Linens may be removed from cribs only

24  for laundering purposes.

25         (4)  Bed linens must be changed at least once every

26  other day.

27         (5)  Antimicrobial soap and disposable paper towels

28  must be provided at each sink.

29         (6)  Children suspected of having a communicable

30  disease that may be transmitted through casual contact, as

31  determined by the facility's medical director, must be

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  1  isolated and the parents notified of the condition. Isolation

  2  must be continued until a physician or advanced registered

  3  nurse practitioner determines communicability has passed.

  4         (7)  SPPEAC center staff members suspected of having a

  5  communicable disease may not return to the SPPEAC center until

  6  the signs and symptoms that relate to the communicable disease

  7  are no longer present, as evidenced by a written statement

  8  from a physician or advanced registered nurse practitioner.

  9         Section 21.  Transportation services.--If

10  transportation is provided by a SPPEAC center and prescribed

11  by the primary physician or advanced registered nurse

12  practitioner, a procedure delineating personnel and equipment

13  to accompany the child must be included in the procedure

14  manual of the SPPEAC center.

15         Section 22.  Emergency procedures.--

16         (1)  Each SPPEAC center shall conform to the minimum

17  standards for child care facilities adopted by the State Fire

18  Marshal and shall be inspected annually by a certified fire

19  inspector. The center must maintain a copy of the current

20  annual fire inspection report at the center.

21         (2)  The center must have a working telephone that is

22  not locked and that is not a pay telephone.

23         (3)  Emergency telephone numbers must be posted on or

24  in the immediate vicinity of all telephones.

25         (4)  Each center must have an emergency power source

26  with sufficient generating power to continue the function of

27  medical equipment in the event of a power failure. The

28  emergency generator must be tested every 30 days and

29  satisfactory mechanical operation must be documented on a log

30  designed for that purpose.

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    Florida House of Representatives - 2002                 HB 597

    778-121-02






  1         (5)  Emergency transportation of a child must be

  2  performed by a licensed emergency medical services provider,

  3  with a SPPEAC center staff member accompanying the child.

  4         Section 23.  This act shall take effect October 1,

  5  2002.

  6

  7            *****************************************

  8                       LEGISLATIVE SUMMARY

  9
      Requires the Agency for Health Care Administration to
10    license subacute pediatric prescribed extended
      alternative care centers that provide care for medically
11    fragile or technologically dependent children. Specifies
      requirements for obtaining and maintaining such a
12    license. Provides requirements for the professional staff
      employed by a SPPEAC center. Provides requirements for
13    qualify assurance for a center. Specifies minimum
      equipment and supplies that must be maintained by a
14    center. (See bill for details.)

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