HB 1009

CS

CHAMBER ACTION

1	The Health Care Appropriations Committee recommends the
2	following:
3
4	Council/Committee Substitute
5	Remove the entire bill and insert:
6	A bill to be entitled
7	An act relating to physician supervision standards;
8	amending s. 458.348, F.S.; defining the term "physician
9	office practice setting"; providing requirements for
10	supervisory relationships with advanced registered nurse
11	practitioners or physician assistants practicing outside
12	the physician office practice setting; providing
13	rulemaking authority; providing grounds for discipline;
14	exempting certain advanced registered nurse practitioners
15	and physician assistants from certain supervisory
16	relationships and requirements; creating s. 459.025, F.S.;
17	requiring osteopathic physicians in a supervisory
18	relationship with certain professionals to provide notice;
19	providing for protocols requiring direct supervision;
20	defining the term "osteopathic physician office practice
21	setting"; providing requirements for supervisory
22	relationships with advanced registered nurse practitioners
23	or physician assistants practicing outside the osteopathic
24	physician office practice setting; providing rulemaking
25	authority; providing grounds for discipline; exempting
26	certain advanced registered nurse practitioners and
27	physician assistants from certain supervisory
28	relationships and requirements; providing an effective
29	date.
30
31	Be It Enacted by the Legislature of the State of Florida:
32
33	Section 1.  Section 458.348, Florida Statutes, is amended
34	to read:
35	458.348  Formal supervisory relationships, standing orders,
36	and established protocols; notice; standards; supervisory
37	relationships with advanced registered nurse practitioners or
38	physician assistants practicing outside the physician office
39	practice setting; exemptions.--
40	(1)  NOTICE.--
41	(a)  When a physician enters into a formal supervisory
42	relationship or standing orders with an emergency medical
43	technician or paramedic licensed pursuant to s. 401.27, which
44	relationship or orders contemplate the performance of medical
45	acts, or when a physician enters into an established protocol
46	with an advanced registered nurse practitioner, which protocol
47	contemplates the performance of medical acts identified and
48	approved by the joint committee pursuant to s. 464.003(3)(c) or
49	acts set forth in s. 464.012(3) and (4), the physician shall
50	submit notice to the board. The notice shall contain a statement
51	in substantially the following form:
52
53	I,   (name and professional license number of physician)  ,
54	of   (address of physician)   have hereby entered into a formal
55	supervisory relationship, standing orders, or an established
56	protocol with   (number of persons)   emergency medical
57	technician(s),   (number of persons)   paramedic(s), or
58	(number of persons)   advanced registered nurse practitioner(s).
59	(b)  Notice shall be filed within 30 days after of entering
60	into the relationship, orders, or protocol. Notice also shall be
61	provided within 30 days after the physician has terminated any
62	such relationship, orders, or protocol.
63	(2)  ESTABLISHMENT OF STANDARDS BY JOINT COMMITTEE.--The
64	joint committee created by s. 464.003(3)(c) shall determine
65	minimum standards for the content of established protocols
66	pursuant to which an advanced registered nurse practitioner may
67	perform medical acts identified and approved by the joint
68	committee pursuant to s. 464.003(3)(c) or acts set forth in s.
69	464.012(3) and (4) and shall determine minimum standards for
70	supervision of such acts by the physician, unless the joint
71	committee determines that any act set forth in s. 464.012(3) or
72	(4) is not a medical act. Such standards shall be based on risk
73	to the patient and acceptable standards of medical care and
74	shall take into account the special problems of medically
75	underserved areas. The standards developed by the joint
76	committee shall be adopted as rules by the Board of Nursing and
77	the Board of Medicine for purposes of carrying out their
78	responsibilities pursuant to part I of chapter 464 and this
79	chapter, respectively, but neither board shall have disciplinary
80	powers over the licensees of the other board.
81	(3)  PROTOCOLS REQUIRING DIRECT SUPERVISION.--All protocols
82	relating to electrolysis or electrology using laser or
83	light-based hair removal or reduction by persons other than
84	physicians licensed under this chapter or chapter 459 shall
85	require the person performing such service to be appropriately
86	trained and work only under the direct supervision and
87	responsibility of a physician licensed under this chapter or
88	chapter 459.
89	(4)  SUPERVISORY RELATIONSHIPS WITH ADVANCED REGISTERED
90	NURSE PRACTITIONERS OR PHYSICIAN ASSISTANTS PRACTICING OUTSIDE
91	THE PHYSICIAN OFFICE PRACTICE SETTING.--
92	(a)  For purposes of this subsection, the term "physician
93	office practice setting" means a business location where a
94	physician delivers medical services regardless of whether the
95	business is physician owned or nonphysician owned. A physician
96	office practice setting includes a location where medical
97	services are performed other than at a hospital, an ambulatory
98	surgical center, an abortion clinic, or any other medical
99	facility licensed by the Department of Health, the Agency for
100	Health Care Administration, the Department of Corrections, a
101	successor agency, or a certified rural health clinic. A business
102	location is a physician office practice setting if a physician
103	is physically present in the business location during the
104	provision of care greater than 40 hours during every 21
105	consecutive calendar days. A business location that does not
106	meet this requirement shall be considered outside a physician
107	office practice setting, irrespective of the ownership or
108	business name of the site.
109	(b)  A physician who is in a supervisory relationship with
110	an advanced registered nurse practitioner as described in s.
111	464.012(4)(c) or a physician assistant as described in s.
112	458.347(2)(f) who is practicing outside a physician office
113	practice setting of the supervising physician shall:
114	1.  Maintain a valid and unrestricted active Florida
115	license pursuant to this chapter and a valid federal controlled
116	substance registry number pursuant to chapter 893.
117	2.  Provide indirect supervision as defined by the Board of
118	Medicine to the advanced registered nurse practitioner or
119	physician assistant.
120	3.  Notwithstanding the number of supervisory relationships
121	authorized in s. 458.347(3), maintain no more than four
122	supervisory relationships with any combination of advanced
123	registered nurse practitioners or physician assistants outside
124	the physician office practice setting at any one time.
125	4.  Delegate only tasks and procedures to the advanced
126	registered nurse practitioner or physician assistant which are
127	within the supervising physician's practice and medical
128	specialty area.
129	5.  Ensure that the advanced registered nurse practitioner
130	or physician assistant has been actively practicing within the
131	medical specialty area for a minimum of 4 years prior to
132	providing care in a practice setting outside the physician
133	office practice setting of the supervising physician.
134	6.  Ensure that the advanced registered nurse practitioner
135	or physician assistant under supervision wears identification
136	that clearly identifies to the patient that he or she is an
137	advanced registered nurse practitioner or a physician assistant.
138	7.  Document consultation, occurring a minimum of every 21
139	calendar days, with the advanced registered nurse practitioner
140	or physician assistant, during which patient medical files and
141	care plans managed by the advanced registered nurse practitioner
142	or physician assistant during the preceding 21 calendar days are
143	evaluated.
144	(5)  RULES.--The Board of Medicine may adopt rules to
145	administer this section. The Board of Medicine shall take into
146	consideration existing rules and laws governing supervision, as
147	well as assessment, diagnosis, treatment, and procedures that
148	are safely performed by an advanced registered nurse
149	practitioner or physician assistant under indirect supervision.
150	(6)  FAILURE TO COMPLY.--Any licensee failing to comply
151	with this section or any rule adopted pursuant to this section
152	is in violation of s. 458.331(1)(w) or (dd), and such violation
153	constitutes grounds for denial of license or disciplinary
154	action, as specified in s. 456.072(2).
155	(7)  EXEMPTIONS.--The requirements of this section shall
156	not apply to advanced registered nurse practitioners or
157	physician assistants providing services in a nursing home
158	licensed under part II of chapter 400, an assisted living
159	facility licensed under part III of chapter 400, a continuing
160	care facility licensed under chapter 651, or a retirement
161	community consisting of independent living units and either a
162	licensed nursing home or assisted living facility. The
163	requirements of this section shall not apply to advanced
164	registered nurse practitioners or physician assistants providing
165	services to persons enrolled in a program designed to maintain
166	elders and persons with disabilities in a home and community-
167	based setting.
168	Section 2.  Section 459.025, Florida Statutes, is created
169	to read:
170	459.025  Formal supervisory relationships, standing orders,
171	and established protocols; notice; standards; supervisory
172	relationships with advanced registered nurse practitioners or
173	physician assistants practicing outside the osteopathic
174	physician office practice setting; exemptions.--
175	(1)  NOTICE.--
176	(a)  When an osteopathic physician enters into a formal
177	supervisory relationship or standing orders with an emergency
178	medical technician or paramedic licensed pursuant to s. 401.27,
179	which relationship or orders contemplate the performance of
180	medical acts, or when an osteopathic physician enters into an
181	established protocol with an advanced registered nurse
182	practitioner, which protocol contemplates the performance of
183	medical acts identified and approved by the joint committee
184	pursuant to s. 464.003(3)(c) or acts set forth in s. 464.012(3)
185	and (4), the osteopathic physician shall submit notice to the
186	board. The notice shall contain a statement in substantially the
187	following form:
188
189	I,   (name and professional license number of osteopathic
190	physician)  , of   (address of osteopathic physician)   have
191	hereby entered into a formal supervisory relationship, standing
192	orders, or an established protocol with   (number of persons)
193	emergency medical technician(s),   (number of persons)
194	paramedic(s), or   (number of persons)   advanced registered
195	nurse practitioner(s).
196	(b)  Notice shall be filed within 30 days after entering
197	into the relationship, orders, or protocol. Notice also shall be
198	provided within 30 days after the osteopathic physician has
199	terminated any such relationship, orders, or protocol.
200	(2)  PROTOCOLS REQUIRING DIRECT SUPERVISION.--All protocols
201	relating to electrolysis or electrology using laser or
202	light-based hair removal or reduction by persons other than
203	osteopathic physicians licensed under this chapter shall require
204	the person performing such service to be appropriately trained
205	and work only under the direct supervision and responsibility of
206	an osteopathic physician licensed under this chapter.
207	(3)  SUPERVISORY RELATIONSHIPS WITH ADVANCED REGISTERED
208	NURSE PRACTITIONERS OR PHYSICIAN ASSISTANTS PRACTICING OUTSIDE
209	THE PHYSICIAN OFFICE PRACTICE SETTING.--
210	(a)  For purposes of this subsection, the term "osteopathic
211	physician office practice setting" means a business location
212	where an osteopathic physician delivers medical services
213	regardless of whether the business is osteopathic physician
214	owned or nonphysician owned. An osteopathic physician office
215	practice setting includes a location where medical services are
216	performed other than at a hospital, an ambulatory surgical
217	center, an abortion clinic, or any other medical facility
218	licensed by the Department of Health, the Agency for Health Care
219	Administration, the Department of Corrections, a successor
220	agency, or a certified rural health clinic. A business location
221	is an osteopathic physician office practice setting if an
222	osteopathic physician is physically present in the business
223	location during the provision of care greater than 40 hours
224	during every 21 consecutive calendar days. A business location
225	that does not meet this requirement shall be considered outside
226	an osteopathic physician office practice setting, irrespective
227	of the ownership or business name of the site.
228	(b)  An osteopathic physician who is in a supervisory
229	relationship with an advanced registered nurse practitioner as
230	described in s. 464.012(4)(c) or a physician assistant as
231	described in s. 459.022(2)(f) who is practicing outside an
232	osteopathic physician office practice setting of the supervising
233	osteopathic physician shall:
234	1.  Maintain a valid and unrestricted active Florida
235	license pursuant to this chapter and a valid federal controlled
236	substance registry number pursuant to chapter 893.
237	2.  Provide indirect supervision as defined by the Board of
238	Osteopathic Medicine to the advanced registered nurse
239	practitioner or physician assistant.
240	3.  Notwithstanding the number of supervisory relationships
241	authorized in s. 459.022(3), maintain no more than four
242	supervisory relationships with any combination of advanced
243	registered nurse practitioners or physician assistants outside
244	the osteopathic physician office practice setting at any one
245	time.
246	4.  Delegate only tasks and procedures to the advanced
247	registered nurse practitioner or physician assistant which are
248	within the supervising osteopathic physician's practice and
249	medical specialty area.
250	5.  Ensure that the advanced registered nurse practitioner
251	or physician assistant has been actively practicing within the
252	medical specialty area for a minimum of 4 years prior to
253	providing care in a practice setting outside the osteopathic
254	physician office practice setting of the supervising osteopathic
255	physician.
256	6.  Ensure that the advanced registered nurse practitioner
257	or physician assistant under supervision wears identification
258	that clearly identifies to the patient that he or she is an
259	advanced registered nurse practitioner or a physician assistant.
260	7.  Document consultation, occurring a minimum of every 21
261	calendar days, with the advanced registered nurse practitioner
262	or physician assistant, during which patient medical files and
263	care plans managed by the advanced registered nurse practitioner
264	or physician assistant during the preceding 21 calendar days are
265	evaluated.
266	(4)  RULES.--The Board of Osteopathic Medicine may adopt
267	rules to administer this section. The Board of Osteopathic
268	Medicine shall take into consideration existing rules and laws
269	governing supervision, as well as assessment, diagnosis,
270	treatment, and procedures that are safely performed by an
271	advanced registered nurse practitioner or physician assistant
272	under indirect supervision.
273	(5)  FAILURE TO COMPLY.--Any licensee failing to comply
274	with this section or any rule adopted pursuant to this section
275	is in violation of s. 459.015(1)(aa) or (hh), and such violation
276	constitutes grounds for denial of license or disciplinary
277	action, as specified in s. 456.072(2).
278	(6)  EXEMPTIONS.--The requirements of this section shall
279	not apply to advanced registered nurse practitioners or
280	physician assistants providing services in a nursing home
281	licensed under part II of chapter 400, an assisted living
282	facility licensed under part III of chapter 400, a continuing
283	care facility licensed under chapter 651, or a retirement
284	community consisting of independent living units and either a
285	licensed nursing home or assisted living facility. The
286	requirements of this section shall not apply to advanced
287	registered nurse practitioners or physician assistants providing
288	services to persons enrolled in a program designed to maintain
289	elders and persons with disabilities in a home and community-
290	based setting.
291	Section 3.  This act shall take effect upon becoming a law.

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