HB 1009CS

CHAMBER ACTION




1The Health Care Appropriations Committee recommends the
2following:
3
4     Council/Committee Substitute
5     Remove the entire bill and insert:
6
A bill to be entitled
7An act relating to physician supervision standards;
8amending s. 458.348, F.S.; defining the term "physician
9office practice setting"; providing requirements for
10supervisory relationships with advanced registered nurse
11practitioners or physician assistants practicing outside
12the physician office practice setting; providing
13rulemaking authority; providing grounds for discipline;
14exempting certain advanced registered nurse practitioners
15and physician assistants from certain supervisory
16relationships and requirements; creating s. 459.025, F.S.;
17requiring osteopathic physicians in a supervisory
18relationship with certain professionals to provide notice;
19providing for protocols requiring direct supervision;
20defining the term "osteopathic physician office practice
21setting"; providing requirements for supervisory
22relationships with advanced registered nurse practitioners
23or physician assistants practicing outside the osteopathic
24physician office practice setting; providing rulemaking
25authority; providing grounds for discipline; exempting
26certain advanced registered nurse practitioners and
27physician assistants from certain supervisory
28relationships and requirements; providing an effective
29date.
30
31Be It Enacted by the Legislature of the State of Florida:
32
33     Section 1.  Section 458.348, Florida Statutes, is amended
34to read:
35     458.348  Formal supervisory relationships, standing orders,
36and established protocols; notice; standards; supervisory
37relationships with advanced registered nurse practitioners or
38physician assistants practicing outside the physician office
39practice setting; exemptions.--
40     (1)  NOTICE.--
41     (a)  When a physician enters into a formal supervisory
42relationship or standing orders with an emergency medical
43technician or paramedic licensed pursuant to s. 401.27, which
44relationship or orders contemplate the performance of medical
45acts, or when a physician enters into an established protocol
46with an advanced registered nurse practitioner, which protocol
47contemplates the performance of medical acts identified and
48approved by the joint committee pursuant to s. 464.003(3)(c) or
49acts set forth in s. 464.012(3) and (4), the physician shall
50submit notice to the board. The notice shall contain a statement
51in substantially the following form:
52
53     I,   (name and professional license number of physician)  ,
54of   (address of physician)   have hereby entered into a formal
55supervisory relationship, standing orders, or an established
56protocol with   (number of persons)   emergency medical
57technician(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
60into the relationship, orders, or protocol. Notice also shall be
61provided within 30 days after the physician has terminated any
62such relationship, orders, or protocol.
63     (2)  ESTABLISHMENT OF STANDARDS BY JOINT COMMITTEE.--The
64joint committee created by s. 464.003(3)(c) shall determine
65minimum standards for the content of established protocols
66pursuant to which an advanced registered nurse practitioner may
67perform medical acts identified and approved by the joint
68committee pursuant to s. 464.003(3)(c) or acts set forth in s.
69464.012(3) and (4) and shall determine minimum standards for
70supervision of such acts by the physician, unless the joint
71committee 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
73to the patient and acceptable standards of medical care and
74shall take into account the special problems of medically
75underserved areas. The standards developed by the joint
76committee shall be adopted as rules by the Board of Nursing and
77the Board of Medicine for purposes of carrying out their
78responsibilities pursuant to part I of chapter 464 and this
79chapter, respectively, but neither board shall have disciplinary
80powers over the licensees of the other board.
81     (3)  PROTOCOLS REQUIRING DIRECT SUPERVISION.--All protocols
82relating to electrolysis or electrology using laser or
83light-based hair removal or reduction by persons other than
84physicians licensed under this chapter or chapter 459 shall
85require the person performing such service to be appropriately
86trained and work only under the direct supervision and
87responsibility of a physician licensed under this chapter or
88chapter 459.
89     (4)  SUPERVISORY RELATIONSHIPS WITH ADVANCED REGISTERED
90NURSE PRACTITIONERS OR PHYSICIAN ASSISTANTS PRACTICING OUTSIDE
91THE PHYSICIAN OFFICE PRACTICE SETTING.--
92     (a)  For purposes of this subsection, the term "physician
93office practice setting" means a business location where a
94physician delivers medical services regardless of whether the
95business is physician owned or nonphysician owned. A physician
96office practice setting includes a location where medical
97services are performed other than at a hospital, an ambulatory
98surgical center, an abortion clinic, or any other medical
99facility licensed by the Department of Health, the Agency for
100Health Care Administration, the Department of Corrections, a
101successor agency, or a certified rural health clinic. A business
102location is a physician office practice setting if a physician
103is physically present in the business location during the
104provision of care greater than 40 hours during every 21
105consecutive calendar days. A business location that does not
106meet this requirement shall be considered outside a physician
107office practice setting, irrespective of the ownership or
108business name of the site.
109     (b)  A physician who is in a supervisory relationship with
110an advanced registered nurse practitioner as described in s.
111464.012(4)(c) or a physician assistant as described in s.
112458.347(2)(f) who is practicing outside a physician office
113practice setting of the supervising physician shall:
114     1.  Maintain a valid and unrestricted active Florida
115license pursuant to this chapter and a valid federal controlled
116substance registry number pursuant to chapter 893.
117     2.  Provide indirect supervision as defined by the Board of
118Medicine to the advanced registered nurse practitioner or
119physician assistant.
120     3.  Notwithstanding the number of supervisory relationships
121authorized in s. 458.347(3), maintain no more than four
122supervisory relationships with any combination of advanced
123registered nurse practitioners or physician assistants outside
124the physician office practice setting at any one time.
125     4.  Delegate only tasks and procedures to the advanced
126registered nurse practitioner or physician assistant which are
127within the supervising physician's practice and medical
128specialty area.
129     5.  Ensure that the advanced registered nurse practitioner
130or physician assistant has been actively practicing within the
131medical specialty area for a minimum of 4 years prior to
132providing care in a practice setting outside the physician
133office practice setting of the supervising physician.
134     6.  Ensure that the advanced registered nurse practitioner
135or physician assistant under supervision wears identification
136that clearly identifies to the patient that he or she is an
137advanced registered nurse practitioner or a physician assistant.
138     7.  Document consultation, occurring a minimum of every 21
139calendar days, with the advanced registered nurse practitioner
140or physician assistant, during which patient medical files and
141care plans managed by the advanced registered nurse practitioner
142or physician assistant during the preceding 21 calendar days are
143evaluated.
144     (5)  RULES.--The Board of Medicine may adopt rules to
145administer this section. The Board of Medicine shall take into
146consideration existing rules and laws governing supervision, as
147well as assessment, diagnosis, treatment, and procedures that
148are safely performed by an advanced registered nurse
149practitioner or physician assistant under indirect supervision.
150     (6)  FAILURE TO COMPLY.--Any licensee failing to comply
151with this section or any rule adopted pursuant to this section
152is in violation of s. 458.331(1)(w) or (dd), and such violation
153constitutes grounds for denial of license or disciplinary
154action, as specified in s. 456.072(2).
155     (7)  EXEMPTIONS.--The requirements of this section shall
156not apply to advanced registered nurse practitioners or
157physician assistants providing services in a nursing home
158licensed under part II of chapter 400, an assisted living
159facility licensed under part III of chapter 400, a continuing
160care facility licensed under chapter 651, or a retirement
161community consisting of independent living units and either a
162licensed nursing home or assisted living facility. The
163requirements of this section shall not apply to advanced
164registered nurse practitioners or physician assistants providing
165services to persons enrolled in a program designed to maintain
166elders and persons with disabilities in a home and community-
167based setting.
168     Section 2.  Section 459.025, Florida Statutes, is created
169to read:
170     459.025  Formal supervisory relationships, standing orders,
171and established protocols; notice; standards; supervisory
172relationships with advanced registered nurse practitioners or
173physician assistants practicing outside the osteopathic
174physician office practice setting; exemptions.--
175     (1)  NOTICE.--
176     (a)  When an osteopathic physician enters into a formal
177supervisory relationship or standing orders with an emergency
178medical technician or paramedic licensed pursuant to s. 401.27,
179which relationship or orders contemplate the performance of
180medical acts, or when an osteopathic physician enters into an
181established protocol with an advanced registered nurse
182practitioner, which protocol contemplates the performance of
183medical acts identified and approved by the joint committee
184pursuant to s. 464.003(3)(c) or acts set forth in s. 464.012(3)
185and (4), the osteopathic physician shall submit notice to the
186board. The notice shall contain a statement in substantially the
187following form:
188
189     I,   (name and professional license number of osteopathic
190physician)  , of   (address of osteopathic physician)   have
191hereby entered into a formal supervisory relationship, standing
192orders, or an established protocol with   (number of persons)  
193emergency medical technician(s),   (number of persons)  
194paramedic(s), or   (number of persons)   advanced registered
195nurse practitioner(s).
196     (b)  Notice shall be filed within 30 days after entering
197into the relationship, orders, or protocol. Notice also shall be
198provided within 30 days after the osteopathic physician has
199terminated any such relationship, orders, or protocol.
200     (2)  PROTOCOLS REQUIRING DIRECT SUPERVISION.--All protocols
201relating to electrolysis or electrology using laser or
202light-based hair removal or reduction by persons other than
203osteopathic physicians licensed under this chapter shall require
204the person performing such service to be appropriately trained
205and work only under the direct supervision and responsibility of
206an osteopathic physician licensed under this chapter.
207     (3)  SUPERVISORY RELATIONSHIPS WITH ADVANCED REGISTERED
208NURSE PRACTITIONERS OR PHYSICIAN ASSISTANTS PRACTICING OUTSIDE
209THE PHYSICIAN OFFICE PRACTICE SETTING.--
210     (a)  For purposes of this subsection, the term "osteopathic
211physician office practice setting" means a business location
212where an osteopathic physician delivers medical services
213regardless of whether the business is osteopathic physician
214owned or nonphysician owned. An osteopathic physician office
215practice setting includes a location where medical services are
216performed other than at a hospital, an ambulatory surgical
217center, an abortion clinic, or any other medical facility
218licensed by the Department of Health, the Agency for Health Care
219Administration, the Department of Corrections, a successor
220agency, or a certified rural health clinic. A business location
221is an osteopathic physician office practice setting if an
222osteopathic physician is physically present in the business
223location during the provision of care greater than 40 hours
224during every 21 consecutive calendar days. A business location
225that does not meet this requirement shall be considered outside
226an osteopathic physician office practice setting, irrespective
227of the ownership or business name of the site.
228     (b)  An osteopathic physician who is in a supervisory
229relationship with an advanced registered nurse practitioner as
230described in s. 464.012(4)(c) or a physician assistant as
231described in s. 459.022(2)(f) who is practicing outside an
232osteopathic physician office practice setting of the supervising
233osteopathic physician shall:
234     1.  Maintain a valid and unrestricted active Florida
235license pursuant to this chapter and a valid federal controlled
236substance registry number pursuant to chapter 893.
237     2.  Provide indirect supervision as defined by the Board of
238Osteopathic Medicine to the advanced registered nurse
239practitioner or physician assistant.
240     3.  Notwithstanding the number of supervisory relationships
241authorized in s. 459.022(3), maintain no more than four
242supervisory relationships with any combination of advanced
243registered nurse practitioners or physician assistants outside
244the osteopathic physician office practice setting at any one
245time.
246     4.  Delegate only tasks and procedures to the advanced
247registered nurse practitioner or physician assistant which are
248within the supervising osteopathic physician's practice and
249medical specialty area.
250     5.  Ensure that the advanced registered nurse practitioner
251or physician assistant has been actively practicing within the
252medical specialty area for a minimum of 4 years prior to
253providing care in a practice setting outside the osteopathic
254physician office practice setting of the supervising osteopathic
255physician.
256     6.  Ensure that the advanced registered nurse practitioner
257or physician assistant under supervision wears identification
258that clearly identifies to the patient that he or she is an
259advanced registered nurse practitioner or a physician assistant.
260     7.  Document consultation, occurring a minimum of every 21
261calendar days, with the advanced registered nurse practitioner
262or physician assistant, during which patient medical files and
263care plans managed by the advanced registered nurse practitioner
264or physician assistant during the preceding 21 calendar days are
265evaluated.
266     (4)  RULES.--The Board of Osteopathic Medicine may adopt
267rules to administer this section. The Board of Osteopathic
268Medicine shall take into consideration existing rules and laws
269governing supervision, as well as assessment, diagnosis,
270treatment, and procedures that are safely performed by an
271advanced registered nurse practitioner or physician assistant
272under indirect supervision.
273     (5)  FAILURE TO COMPLY.--Any licensee failing to comply
274with this section or any rule adopted pursuant to this section
275is in violation of s. 459.015(1)(aa) or (hh), and such violation
276constitutes grounds for denial of license or disciplinary
277action, as specified in s. 456.072(2).
278     (6)  EXEMPTIONS.--The requirements of this section shall
279not apply to advanced registered nurse practitioners or
280physician assistants providing services in a nursing home
281licensed under part II of chapter 400, an assisted living
282facility licensed under part III of chapter 400, a continuing
283care facility licensed under chapter 651, or a retirement
284community consisting of independent living units and either a
285licensed nursing home or assisted living facility. The
286requirements of this section shall not apply to advanced
287registered nurse practitioners or physician assistants providing
288services to persons enrolled in a program designed to maintain
289elders and persons with disabilities in a home and community-
290based setting.
291     Section 3.  This act shall take effect upon becoming a law.


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