HB 0699

CS

CHAMBER ACTION

1	The Health Care General Committee recommends the following:
2	Council/Committee Substitute
3	Remove the entire bill and insert:
4	A bill to be entitled
5	An act relating to health care; amending s. 456.041, F.S.;
6	requiring certain protocols to be included in advanced
7	registered nurse practitioner profiles; amending s.
8	458.348, F.S.; providing requirements and standards for
9	physicians relating to supervisory relationships in
10	medical office settings; providing definitions; providing
11	exemptions; providing requirements relating to the
12	referral of a patient by another practitioner; creating s.
13	459.025, F.S.; providing requirements and standards for
14	osteopathic physicians relating to supervisory
15	relationships in medical office settings; providing
16	definitions; providing exemptions; providing requirements
17	relating to the referral of a patient by another
18	practitioner; amending s. 464.012, F.S.; providing
19	additional requirements relating to protocols established
20	for advanced registered nurse practitioners; providing an
21	effective date.
22
23	Be It Enacted by the Legislature of the State of Florida:
24	Section 1.  Paragraph (a) of subsection (1) of section
25	456.041, Florida Statutes, is amended to read:
26	456.041  Practitioner profile; creation.--
27	(1)(a)  The Department of Health shall compile the
28	information submitted pursuant to s. 456.039 into a practitioner
29	profile of the applicant submitting the information, except that
30	the Department of Health shall develop a format to compile
31	uniformly any information submitted under s. 456.039(4)(b).
32	Beginning July 1, 2001, the Department of Health may compile the
33	information submitted pursuant to s. 456.0391 into a
34	practitioner profile of the applicant submitting the
35	information. The protocol submitted pursuant to s. 464.012(3)
36	shall be included in the practitioner profile of the advanced
37	registered nurse practitioner applicant submitting the
38	information.
39	Section 2.  Subsections (4) and (5) are added to section
40	458.348, Florida Statutes, to read:
41	458.348  Formal supervisory relationships, standing orders,
42	and established protocols; notice; standards.--
43	(4)  SUPERVISORY RELATIONSHIPS IN MEDICAL OFFICE
44	SETTINGS.--A physician who supervises an advanced registered
45	nurse practitioner or physician assistant at a medical office
46	other than the physician's primary practice location, where the
47	advanced registered nurse practitioner or physician assistant is
48	not under the onsite supervision of a supervising physician,
49	shall comply with the standards set forth in this subsection.
50	For the purpose of this subsection, a physician's "primary
51	practice location" means the address reflected on the
52	practitioner's profile published pursuant to s. 456.041.
53	(a)  A physician who is engaged in providing primary health
54	care services may not supervise more than four offices in
55	addition to the physician's primary practice location. For the
56	purpose of this subsection, "primary health care" means health
57	care services that are commonly provided to patients without
58	referral from another practitioner and excludes practices
59	providing primarily dermatologic and skin care services,
60	including aesthetic skin care services.
61	(b)  A physician who is engaged in providing specialty
62	health care services may not supervise more than two offices in
63	addition to the physician's primary practice location. For the
64	purpose of this subsection, "specialty health care" means health
65	care services that are commonly provided to patients with a
66	referral from another practitioner and excludes practices
67	providing primarily dermatologic and skin care services,
68	including aesthetic skin care services.
69	(c)  A physician who supervises an advanced registered
70	nurse practitioner or physician assistant at a medical office
71	other than the physician's primary practice location, where the
72	advanced registered nurse practitioner or physician assistant is
73	not under the onsite supervision of a supervising physician and
74	the services offered at the office are primarily dermatologic or
75	skin care services, including aesthetic skin care services,
76	other than plastic surgery, shall comply with the standards
77	listed in subparagraphs 1.-4. Notwithstanding the provisions of
78	s. 458.347(4)(e)8. or any administrative rule, a physician
79	supervising a physician assistant shall not be required to
80	review and sign charts or medical records prepared by the
81	physician assistant.
82	1.  The physician shall submit to the board the addresses
83	of all offices where he or she is supervising an advanced
84	registered nurse practitioner or a physician assistant that are
85	not the physician's primary practice location.
86	2.  The physician shall be either board certified or board
87	eligible in dermatology or plastic surgery as recognized by the
88	board under s. 458.3312.
89	3.  All offices where the physician is supervising an
90	advanced registered nurse practitioner or a physician assistant
91	that are not the physician's primary place of practice shall be
92	within 25 miles of the physician's primary place of practice or
93	in a county that is contiguous to the county of the physician's
94	primary place of practice. However, the distance between any of
95	the offices may not exceed 75 miles.
96	4.  The physician may only supervise one office other than
97	the physician's primary place of practice except that until July
98	1, 2011, the physician may supervise up to two medical offices
99	other than the physician's primary place of practice if the
100	addresses of the offices are submitted to the board prior to
101	July 1, 2006. Effective July 1, 2011, the physician may
102	supervise only one office other than the physician's primary
103	place of practice regardless of when the addresses of the
104	offices were submitted to the board.
105	(d)  A physician who supervises an office in addition to
106	the physician's primary practice location shall conspicuously
107	post in each of the physician's offices a current schedule of
108	the regular hours that the physician is present in that office
109	and the hours that the office is open when the physician is not
110	present.
111	(e)  The provisions of this subsection shall not apply to
112	health care services provided in facilities licensed under
113	chapter 395 or in conjunction with a college of medicine,
114	college of nursing, or an accredited graduate medical or nursing
115	education program; to health care services provided in a nursing
116	home licensed under part II of chapter 400, an assisted living
117	facility licensed under part III of chapter 400, a continuing
118	care facility licensed under chapter 651, or a retirement
119	community consisting of independent living units and either a
120	licensed nursing home or assisted living facility; to anesthesia
121	services provided in accordance with law; to health care
122	services provided in a designated rural health clinic; to health
123	care services provided to persons enrolled in a program designed
124	to maintain elders and persons with disabilities in a home and
125	community-based setting; or to health care services provided in
126	federal or state facilities.
127	(5)  REFERRALS.--Upon initial referral of a patient by
128	another practitioner, the physician receiving the referral shall
129	ensure that the patient is informed of the type of license held
130	by the physician and the type of license held by any other
131	practitioner who will be providing services to the patient. When
132	scheduling the initial examination or consultation following the
133	referral, the patient may decide to see the physician or any
134	other licensed practitioner supervised by the physician and
135	prior to the initial examination or consultation shall sign a
136	form indicating the patient's choice of practitioner. The
137	supervising physician shall review the medical record of the
138	initial examination or consultation and ensure that a written
139	report on the initial examination or consultation is furnished
140	to the referring practitioner within 10 business days following
141	the completion of the initial examination or consultation.
142	Section 3.  Section 459.025, Florida Statutes, is created
143	to read:
144	459.025  Formal supervisory relationships, standing orders,
145	and established protocols; notice; standard.--
146	(1)  NOTICE.--
147	(a)  When a physician enters into a formal supervisory
148	relationship or standing orders with an emergency medical
149	technician or paramedic licensed pursuant to s. 401.27, which
150	relationship or orders contemplate the performance of medical
151	acts, or when a physician enters into an established protocol
152	with an advanced registered nurse practitioner, which protocol
153	contemplates the performance of medical acts identified and
154	approved by the joint committee pursuant to s. 464.003(3)(c) or
155	acts set forth in s. 464.012(3) and (4), the physician shall
156	submit notice to the board. The notice shall contain a statement
157	in substantially the following form:
158
159	I,   (name and professional license number of physician)  ,
160	of   (address of physician)   have hereby entered into a formal
161	supervisory relationship, standing orders, or an established
162	protocol with   (number of persons)   emergency medical
163	technician(s),   (number of persons)   paramedic(s), or
164	(number of persons)   advanced registered nurse practitioner(s).
165	(b)  Notice shall be filed within 30 days of entering into
166	the relationship, orders, or protocol. Notice also shall be
167	provided within 30 days after the physician has terminated any
168	such relationship, orders, or protocol.
169	(2)  PROTOCOLS REQUIRING DIRECT SUPERVISION.--All protocols
170	relating to electrolysis or electrology using laser or
171	light-based hair removal or reduction by persons other than
172	physicians licensed under this chapter or chapter 458 shall
173	require the person performing such service to be appropriately
174	trained and work only under the direct supervision and
175	responsibility of a physician licensed under this chapter or
176	chapter 458.
177	(3)  SUPERVISORY RELATIONSHIPS IN MEDICAL OFFICE
178	SETTINGS.--A physician who supervises an advanced registered
179	nurse practitioner or physician assistant at a medical office
180	other than the physician's primary practice location, where the
181	advanced registered nurse practitioner or physician assistant is
182	not under the onsite supervision of a supervising physician,
183	shall comply with the standards set forth in this subsection.
184	For the purpose of this subsection, a physician's "primary
185	practice location" means the address reflected on the
186	practitioner's profile published pursuant to s. 456.041.
187	(a)  A physician who is engaged in providing primary health
188	care services may not supervise more than four offices in
189	addition to the physician's primary practice location. For the
190	purpose of this subsection, "primary health care" means health
191	care services that are commonly provided to patients without
192	referral from another practitioner and excludes practices
193	providing primarily dermatologic and skin care services,
194	including aesthetic skin care services.
195	(b)  A physician who is engaged in providing specialty
196	health care services may not supervise more than two offices in
197	addition to the physician's primary practice location. For the
198	purpose of this subsection, "specialty health care" means health
199	care services that are commonly provided to patients with a
200	referral from another practitioner and excludes practices
201	providing primarily dermatologic and skin care services,
202	including aesthetic skin care services.
203	(c)  A physician who supervises an advanced registered
204	nurse practitioner or physician assistant at a medical office
205	other than the physician's primary practice location, where the
206	advanced registered nurse practitioner or physician assistant is
207	not under the onsite supervision of a supervising physician and
208	the services offered at the office are primarily dermatologic or
209	skin care services, including aesthetic skin care services,
210	other than plastic surgery, shall comply with the standards
211	listed in subparagraphs 1.-4. Notwithstanding the provisions of
212	s. 459.022(4)(e)8. or any administrative rule, a physician
213	supervising a physician assistant shall not be required to
214	review and sign charts or medical records prepared by the
215	physician assistant.
216	1.  The physician shall submit to the board the addresses
217	of all offices where he or she is supervising an advanced
218	registered nurse practitioner or a physician assistant that are
219	not the physician's primary practice location.
220	2.  The physician shall be either board certified or board
221	eligible in dermatology or plastic surgery as recognized by the
222	board under s. 459.0152.
223	3.  All offices where the physician is supervising an
224	advanced registered nurse practitioner or a physician assistant
225	that are not the physician's primary place of practice shall be
226	within 25 miles of the physician's primary place of practice or
227	in a county that is contiguous to the county of the physician's
228	primary place of practice. However, the distance between any of
229	the offices may not exceed 75 miles.
230	4.  The physician may only supervise one office other than
231	the physician's primary place of practice except that until July
232	1, 2011, the physician may supervise up to two medical offices
233	other than the physician's primary place of practice if the
234	addresses of the offices are submitted to the board prior to
235	July 1, 2006. Effective July 1, 2011, the physician may
236	supervise only one office other than the physician's primary
237	place of practice regardless of when the addresses of the
238	offices were submitted to the board.
239	(d)  A physician who supervises an office in addition to
240	the physician's primary practice location shall conspicuously
241	post in each of the physician's offices a current schedule of
242	the regular hours that the physician is present in that office
243	and the hours that the office is open when the physician is not
244	present.
245	(e)  The provisions of this subsection shall not apply to
246	health care services provided in facilities licensed under
247	chapter 395 or in conjunction with a college of medicine,
248	college of nursing, or an accredited graduate medical or nursing
249	education program; to health care services provided in a nursing
250	home licensed under part II of chapter 400, an assisted living
251	facility licensed under part III of chapter 400, a continuing
252	care facility licensed under chapter 651, or a retirement
253	community consisting of independent living units and either a
254	licensed nursing home or assisted living facility; to anesthesia
255	services provided in accordance with law; to health care
256	services provided in a designated rural health clinic; to health
257	care services provided to persons enrolled in a program designed
258	to maintain elders and persons with disabilities in a home and
259	community-based setting; or to health care services provided in
260	federal or state facilities.
261	(4)  REFERRALS.--Upon initial referral of a patient by
262	another practitioner, the physician receiving the referral shall
263	ensure that the patient is informed of the type of license held
264	by the physician and the type of license held by any other
265	practitioner who will be providing services to the patient. When
266	scheduling the initial examination or consultation following the
267	referral, the patient may decide to see the physician or any
268	other licensed practitioner supervised by the physician and
269	prior to the initial examination or consultation shall sign a
270	form indicating the patient's choice of practitioner. The
271	supervising physician shall review the medical record of the
272	initial examination or consultation and ensure that a written
273	report on the initial examination or consultation is furnished
274	to the referring practitioner within 10 business days following
275	the completion of the initial examination or consultation.
276	Section 4.  Subsection (3) of section 464.012, Florida
277	Statutes, is amended to read:
278	464.012  Certification of advanced registered nurse
279	practitioners; fees.--
280	(3)  An advanced registered nurse practitioner shall
281	perform those functions authorized in this section within the
282	framework of an established protocol, which shall be filed with
283	the board upon biennial license renewal and within 30 days of
284	entering into a supervisory relationship with a physician or
285	changes to the protocol. The board shall review the protocol to
286	ensure compliance with applicable regulatory standards for
287	protocols. The board shall refer to the department licensees
288	submitting protocols that are not compliant with the regulatory
289	standards for protocols. A practitioner currently licensed under
290	chapter 458, chapter 459, or chapter 466 shall maintain
291	supervision for directing the specific course of medical
292	treatment. Within the established framework, an advanced
293	registered nurse practitioner may:
294	(a)  Monitor and alter drug therapies.
295	(b)  Initiate appropriate therapies for certain conditions.
296	(c)  Perform additional functions as may be determined by
297	rule in accordance with s. 464.003(3)(c).
298	(d)  Order diagnostic tests and physical and occupational
299	therapy.
300	Section 5.  This act shall take effect July 1, 2006.

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