HB 1009

CS

CHAMBER ACTION

1	The Health Care Regulation Committee recommends the following:
2
3	Council/Committee Substitute
4	Remove the entire bill and insert:
5	A bill to be entitled
6	An act relating to physician supervision standards;
7	amending s. 458.348, F.S.; defining the term "physician
8	office practice setting"; providing requirements for
9	supervisory relationships with advanced registered nurse
10	practitioners or physician assistants practicing outside
11	the physician office practice setting; providing
12	rulemaking authority; exempting certain advanced
13	registered nurse practitioners and physician assistants
14	from certain supervisory relationships and requirements;
15	creating s. 459.025, F.S.; requiring osteopathic
16	physicians in a supervisory relationship with certain
17	professionals to provide notice; providing for protocols
18	requiring direct supervision; defining the term
19	"osteopathic physician office practice setting"; providing
20	requirements for supervisory relationships with advanced
21	registered nurse practitioners or physician assistants
22	practicing outside the osteopathic physician office
23	practice setting; providing rulemaking authority;
24	exempting certain advanced registered nurse practitioners
25	and physician assistants from certain supervisory
26	relationships and requirements; providing an effective
27	date.
28
29	Be It Enacted by the Legislature of the State of Florida:
30
31	Section 1.  Section 458.348, Florida Statutes, is amended
32	to read:
33	458.348  Formal supervisory relationships, standing orders,
34	and established protocols; notice; standards; supervisory
35	relationships with advanced registered nurse practitioners or
36	physician assistants practicing outside the physician office
37	practice setting; exemptions.--
38	(1)  NOTICE.--
39	(a)  When a physician enters into a formal supervisory
40	relationship or standing orders with an emergency medical
41	technician or paramedic licensed pursuant to s. 401.27, which
42	relationship or orders contemplate the performance of medical
43	acts, or when a physician enters into an established protocol
44	with an advanced registered nurse practitioner, which protocol
45	contemplates the performance of medical acts identified and
46	approved by the joint committee pursuant to s. 464.003(3)(c) or
47	acts set forth in s. 464.012(3) and (4), the physician shall
48	submit notice to the board. The notice shall contain a statement
49	in substantially the following form:
50
51	I,   (name and professional license number of physician)  ,
52	of   (address of physician)   have hereby entered into a formal
53	supervisory relationship, standing orders, or an established
54	protocol with   (number of persons)   emergency medical
55	technician(s),   (number of persons)   paramedic(s), or
56	(number of persons)   advanced registered nurse practitioner(s).
57	(b)  Notice shall be filed within 30 days after of entering
58	into the relationship, orders, or protocol. Notice also shall be
59	provided within 30 days after the physician has terminated any
60	such relationship, orders, or protocol.
61	(2)  ESTABLISHMENT OF STANDARDS BY JOINT COMMITTEE.--The
62	joint committee created by s. 464.003(3)(c) shall determine
63	minimum standards for the content of established protocols
64	pursuant to which an advanced registered nurse practitioner may
65	perform medical acts identified and approved by the joint
66	committee pursuant to s. 464.003(3)(c) or acts set forth in s.
67	464.012(3) and (4) and shall determine minimum standards for
68	supervision of such acts by the physician, unless the joint
69	committee determines that any act set forth in s. 464.012(3) or
70	(4) is not a medical act. Such standards shall be based on risk
71	to the patient and acceptable standards of medical care and
72	shall take into account the special problems of medically
73	underserved areas. The standards developed by the joint
74	committee shall be adopted as rules by the Board of Nursing and
75	the Board of Medicine for purposes of carrying out their
76	responsibilities pursuant to part I of chapter 464 and this
77	chapter, respectively, but neither board shall have disciplinary
78	powers over the licensees of the other board.
79	(3)  PROTOCOLS REQUIRING DIRECT SUPERVISION.--All protocols
80	relating to electrolysis or electrology using laser or
81	light-based hair removal or reduction by persons other than
82	physicians licensed under this chapter or chapter 459 shall
83	require the person performing such service to be appropriately
84	trained and work only under the direct supervision and
85	responsibility of a physician licensed under this chapter or
86	chapter 459.
87	(4)  SUPERVISORY RELATIONSHIPS WITH ADVANCED REGISTERED
88	NURSE PRACTITIONERS OR PHYSICIAN ASSISTANTS PRACTICING OUTSIDE
89	THE PHYSICIAN OFFICE PRACTICE SETTING.--
90	(a)  For purposes of this subsection, the term "physician
91	office practice setting" means a business location where a
92	physician delivers medical services regardless of whether the
93	business is physician owned or nonphysician owned. A physician
94	office practice setting includes a location where medical
95	services are performed other than at a hospital, an ambulatory
96	surgical center, an abortion clinic, or any other medical
97	facility licensed by the Department of Health, the Agency for
98	Health Care Administration, the Department of Corrections, a
99	successor agency, or a certified rural health clinic. A business
100	location is a physician office practice setting if a physician
101	is physically present in the business location during the
102	provision of care greater than 33 percent of the hours of
103	operation in which medical care is provided. A business location
104	that does not meet this requirement shall be considered outside
105	a physician office practice setting during all hours when a
106	physician is not physically present, irrespective of the
107	ownership or business name of the site.
108	(b)  A physician who is in a supervisory relationship with
109	an advanced registered nurse practitioner as described in s.
110	464.012(4)(c) or a physician assistant as described in s.
111	458.347(2)(f) who is practicing outside a physician office
112	practice setting of the supervising physician shall:
113	1.  Maintain a valid and unrestricted active Florida
114	license pursuant to this chapter and a valid federal controlled
115	substance registry number pursuant to chapter 893.
116	2.  Provide indirect supervision as defined by the Board of
117	Medicine to the advanced registered nurse practitioner or
118	physician assistant.
119	3.  Notwithstanding the number of supervisory relationships
120	authorized in s. 458.347(3), maintain no more than two
121	supervisory relationships with any combination of advanced
122	registered nurse practitioners or physician assistants outside
123	the physician office practice setting at any one time.
124	4.  Delegate only tasks and procedures to the advanced
125	registered nurse practitioner or physician assistant which are
126	within the supervising physician's practice and medical
127	specialty area.
128	5.  Ensure that the advanced registered nurse practitioner
129	or physician assistant has been actively practicing within the
130	medical specialty area for a minimum of 4 years prior to
131	providing care in a practice setting outside the physician
132	office practice setting of the supervising physician.
133	6.  Ensure that the advanced registered nurse practitioner
134	or physician assistant under supervision clearly identifies to
135	the patient that he or she is an advanced registered nurse
136	practitioner or a physician assistant.
137	(5)  RULES.--The Board of Medicine may adopt rules to
138	administer this section.
139	(6)  EXEMPTIONS.--The requirements of this section shall
140	not apply to advanced registered nurse practitioners or
141	physician assistants providing services in a nursing home
142	licensed under part II of chapter 400, an assisted living
143	facility licensed under part III of chapter 400, a continuing
144	care facility licensed under chapter 651, or a retirement
145	community consisting of independent living units and either a
146	licensed nursing home or assisted living facility. The
147	requirements of this section shall not apply to advanced
148	registered nurse practitioners or physician assistants providing
149	services to persons enrolled in a program designed to maintain
150	elders and persons with disabilities in a home and community-
151	based setting.
152	Section 2.  Section 459.025, Florida Statutes, is created
153	to read:
154	459.025  Formal supervisory relationships, standing orders,
155	and established protocols; notice; standards; supervisory
156	relationships with advanced registered nurse practitioners or
157	physician assistants practicing outside the osteopathic
158	physician office practice setting; exemptions.--
159	(1)  NOTICE.--
160	(a)  When an osteopathic physician enters into a formal
161	supervisory relationship or standing orders with an emergency
162	medical technician or paramedic licensed pursuant to s. 401.27,
163	which relationship or orders contemplate the performance of
164	medical acts, or when an osteopathic physician enters into an
165	established protocol with an advanced registered nurse
166	practitioner, which protocol contemplates the performance of
167	medical acts identified and approved by the joint committee
168	pursuant to s. 464.003(3)(c) or acts set forth in s. 464.012(3)
169	and (4), the osteopathic physician shall submit notice to the
170	board. The notice shall contain a statement in substantially the
171	following form:
172
173	I,   (name and professional license number of osteopathic
174	physician)  , of   (address of osteopathic physician)   have
175	hereby entered into a formal supervisory relationship, standing
176	orders, or an established protocol with   (number of persons)
177	emergency medical technician(s),   (number of persons)
178	paramedic(s), or   (number of persons)   advanced registered
179	nurse practitioner(s).
180	(b)  Notice shall be filed within 30 days after entering
181	into the relationship, orders, or protocol. Notice also shall be
182	provided within 30 days after the osteopathic physician has
183	terminated any such relationship, orders, or protocol.
184	(2)  PROTOCOLS REQUIRING DIRECT SUPERVISION.--All protocols
185	relating to electrolysis or electrology using laser or
186	light-based hair removal or reduction by persons other than
187	osteopathic physicians licensed under this chapter shall require
188	the person performing such service to be appropriately trained
189	and work only under the direct supervision and responsibility of
190	an osteopathic physician licensed under this chapter.
191	(3)  SUPERVISORY RELATIONSHIPS WITH ADVANCED REGISTERED
192	NURSE PRACTITIONERS OR PHYSICIAN ASSISTANTS PRACTICING OUTSIDE
193	THE PHYSICIAN OFFICE PRACTICE SETTING.--
194	(a)  For purposes of this subsection, the term "osteopathic
195	physician office practice setting" means a business location
196	where an osteopathic physician delivers medical services
197	regardless of whether the business is osteopathic physician
198	owned or nonphysician owned. An osteopathic physician office
199	practice setting includes a location where medical services are
200	performed other than at a hospital, an ambulatory surgical
201	center, an abortion clinic, or any other medical facility
202	licensed by the Department of Health, the Agency for Health Care
203	Administration, the Department of Corrections, a successor
204	agency, or a certified rural health clinic. A business location
205	is not an osteopathic physician office practice setting unless
206	an osteopathic physician is physically present in the business
207	location during the provision of care at least 33 percent of the
208	hours of operation in which medical care is provided. A business
209	location that does not meet this requirement shall be considered
210	outside an osteopathic physician office practice setting during
211	all hours when an osteopathic physician is not physically
212	present, irrespective of the ownership or business name of the
213	site.
214	(b)  An osteopathic physician who is in a supervisory
215	relationship with an advanced registered nurse practitioner as
216	described in s. 464.012(4)(c) or a physician assistant as
217	described in s. 459.022(2)(f) who is practicing outside an
218	osteopathic physician office practice setting of the supervising
219	osteopathic physician shall:
220	1.  Maintain a valid and unrestricted active Florida
221	license pursuant to this chapter and a valid federal controlled
222	substance registry number pursuant to chapter 893.
223	2.  Provide indirect supervision as defined by the Board of
224	Osteopathic Medicine to the advanced registered nurse
225	practitioner or physician assistant.
226	3.  Notwithstanding the number of supervisory relationships
227	authorized in s. 459.022(3), maintain no more than two
228	supervisory relationships with any combination of advanced
229	registered nurse practitioners or physician assistants outside
230	the osteopathic physician office practice setting at any one
231	time.
232	4.  Delegate only tasks and procedures to the advanced
233	registered nurse practitioner or physician assistant which are
234	within the supervising osteopathic physician's practice and
235	medical specialty area.
236	5.  Ensure that the advanced registered nurse practitioner
237	or physician assistant has been actively practicing within the
238	medical specialty area for a minimum of 4 years prior to
239	providing care in a practice setting outside the osteopathic
240	physician office practice setting of the supervising osteopathic
241	physician.
242	6.  Ensure that the advanced registered nurse practitioner
243	or physician assistant under supervision clearly identifies to
244	the patient that he or she is an advanced registered nurse
245	practitioner or a physician assistant.
246	(4)  RULES.--The Board of Osteopathic Medicine may adopt
247	rules to administer this section.
248	(5)  EXEMPTIONS.--The requirements of this section shall
249	not apply to advanced registered nurse practitioners or
250	physician assistants providing services in a nursing home
251	licensed under part II of chapter 400, an assisted living
252	facility licensed under part III of chapter 400, a continuing
253	care facility licensed under chapter 651, or a retirement
254	community consisting of independent living units and either a
255	licensed nursing home or assisted living facility. The
256	requirements of this section shall not apply to advanced
257	registered nurse practitioners or physician assistants providing
258	services to persons enrolled in a program designed to maintain
259	elders and persons with disabilities in a home and community-
260	based setting.
261	Section 3.  This act shall take effect upon becoming a law.

CODING: Words stricken are deletions; words underlined are additions.