HB 0699CS

CHAMBER ACTION



1The Health & Families Council recommends the following:
2
3     Council/Committee Substitute
4     Remove the entire bill and insert:
5
A bill to be entitled
6An act relating to health care practitioners; amending s.
7456.041, F.S.; requiring advanced registered nurse
8practitioners to submit protocols to the Department of
9Health as part of practitioner profiles; amending s.
10458.348, F.S.; providing requirements for the supervision
11of certain health care practitioners by physicians;
12providing definitions; providing exemptions; providing
13notice and review requirements relating to the referral of
14a patient by another practitioner; amending s. 459.008,
15F.S.; eliminating an option for osteopathic physicians to
16complete continuing education courses in end-of-life care
17in lieu of continuing education in AIDS/HIV; creating s.
18459.025, F.S.; providing requirements for the supervision
19of certain health care practitioners by osteopathic
20physicians; providing definitions; providing exemptions;
21providing notice and review requirements relating to the
22referral of a patient by another practitioner; amending s.
23464.012, F.S.; requiring certain advanced registered nurse
24practitioners to file protocols with the Board of Nursing;
25specifying requirements relating to the protocols;
26providing an effective date.
27
28Be It Enacted by the Legislature of the State of Florida:
29
30     Section 1.  Paragraph (a) of subsection (1) of section
31456.041, Florida Statutes, is amended to read:
32     456.041  Practitioner profile; creation.--
33     (1)(a)  The Department of Health shall compile the
34information submitted pursuant to s. 456.039 into a practitioner
35profile of the applicant submitting the information, except that
36the Department of Health shall develop a format to compile
37uniformly any information submitted under s. 456.039(4)(b).
38Beginning July 1, 2001, the Department of Health may compile the
39information submitted pursuant to s. 456.0391 into a
40practitioner profile of the applicant submitting the
41information. The protocol submitted pursuant to s. 464.012(3)
42shall be included in the practitioner profile of the applicant
43submitting the information to obtain certification as an
44advanced registered nurse practitioner.
45     Section 2.  Subsections (4) and (5) are added to section
46458.348, Florida Statutes, to read:
47     458.348  Formal supervisory relationships, standing orders,
48and established protocols; notice; standards.--
49     (4)  SUPERVISORY RELATIONSHIPS IN MEDICAL OFFICE
50SETTINGS.--A physician who supervises an advanced registered
51nurse practitioner or physician assistant at a medical office
52other than the physician's primary practice location, where the
53advanced registered nurse practitioner or physician assistant is
54not under the onsite supervision of a supervising physician,
55shall comply with the standards set forth in this subsection.
56For the purpose of this subsection, a physician's "primary
57practice location" means the address reflected on the
58physician's profile published under s. 456.041.
59     (a)  A physician who is engaged in providing primary health
60care services may not supervise more than four offices in
61addition to the physician's primary practice location. For the
62purpose of this subsection, "primary health care" means health
63care services that are commonly provided to patients without
64referral from another practitioner, including obstetrical and
65gynecological services, and excludes practices providing
66primarily dermatologic and skin care services, which include
67aesthetic skin care services.
68     (b)  A physician who is engaged in providing specialty
69health care services may not supervise more than two offices in
70addition to the physician's primary practice location. For the
71purpose of this subsection, "specialty health care" means health
72care services that are commonly provided to patients with a
73referral from another practitioner and excludes practices
74providing primarily dermatologic and skin care services, which
75include aesthetic skin care services.
76     (c)  A physician who supervises an advanced registered
77nurse practitioner or physician assistant at a medical office
78other than the physician's primary practice location, where the
79advanced registered nurse practitioner or physician assistant is
80not under the onsite supervision of a supervising physician and
81the services offered at the office are primarily dermatologic or
82skin care services, which include aesthetic skin care services
83other than plastic surgery, shall comply with the standards
84listed in subparagraphs 1.-4. Notwithstanding s.
85458.347(4)(e)8., a physician supervising a physician assistant
86under this paragraph may not be required to review and cosign
87charts or medical records prepared by the physician assistant.
88     1.  The physician shall submit to the board the addresses
89of all offices where he or she is supervising or has a protocol
90with an advanced registered nurse practitioner or a physician
91assistant that are not the physician's primary practice
92location.
93     2.  The physician shall be board certified or board
94eligible in dermatology or plastic surgery as recognized by the
95board under s. 458.3312.
96     3.  All offices in which the physician is supervising an
97advanced registered nurse practitioner or a physician assistant
98that are not the physician's primary place of practice shall be
99within 25 miles of the physician's primary place of practice or
100in a county that is contiguous to the county of the physician's
101primary place of practice. However, the distance between any of
102the offices may not exceed 75 miles.
103     4.  The physician may supervise only one office other than
104the physician's primary place of practice except that until July
1051, 2011, the physician may supervise up to two medical offices
106other than the physician's primary place of practice if the
107addresses of the offices are submitted to the board prior to
108July 1, 2006. Effective July 1, 2011, the physician may
109supervise only one office other than the physician's primary
110place of practice, regardless of when the addresses of the
111offices were submitted to the board.
112     (d)  A physician who supervises an office in addition to
113the physician's primary practice location shall conspicuously
114post in each of the physician's offices a current schedule of
115the regular hours that the physician is present in that office
116and the hours that the office is open when the physician is not
117present.
118     (e)  This subsection shall not apply to health care
119services provided in facilities licensed under chapter 395 or in
120conjunction with a college of medicine, college of nursing,
121accredited graduate medical program, or nursing education
122program; offices in which the only service being performed is
123hair removal by an advanced registered nurse practitioner or
124physician assistant; not-for-profit, family planning clinics
125that are not licensed pursuant to chapter 390; rural and
126federally qualified health centers; health care services
127provided in a nursing home licensed under part II of chapter
128400, an assisted living facility licensed under part III of
129chapter 400, a continuing care facility licensed under chapter
130651, or a retirement community consisting of independent living
131units and a licensed nursing home or assisted living facility;
132anesthesia services provided in accordance with law; health care
133services provided in a designated rural health clinic; health
134care services provided to persons enrolled in a program designed
135to maintain elderly persons and persons with disabilities in a
136home or community-based setting; university primary care student
137health centers; school health clinics; or health care services
138provided in federal or state facilities.
139     (5)  REQUIREMENTS FOR NOTICE AND REVIEW.--Upon initial
140referral of a patient by another practitioner, the physician
141receiving the referral shall ensure that the patient is informed
142of the type of license held by the physician and the type of
143license held by any other practitioner who will be providing
144services to the patient. When scheduling the initial examination
145or consultation following the referral, the patient may decide
146to see the physician or any other licensed practitioner
147supervised by the physician and, prior to the initial
148examination or consultation, shall sign a form indicating the
149patient's choice of practitioner. The supervising physician
150shall review the medical record of the initial examination or
151consultation and ensure that a written report on the initial
152examination or consultation is furnished to the referring
153practitioner within 10 business days following the completion of
154the initial examination or consultation.
155     Section 3.  Subsection (5) of section 459.008, Florida
156Statutes, is amended to read:
157     459.008  Renewal of licenses and certificates.--
158     (5)  Notwithstanding the provisions of s. 456.033, an
159osteopathic physician may complete continuing education on end-
160of-life and palliative care in lieu of continuing education in
161AIDS/HIV, if that physician has completed the AIDS/HIV
162continuing education in the immediately preceding biennium.
163     Section 4.  Section 459.025, Florida Statutes, is created
164to read:
165     459.025  Formal supervisory relationships, standing orders,
166and established protocols; notice; standards.--
167     (1)  NOTICE.--
168     (a)  When an osteopathic physician enters into a formal
169supervisory relationship or standing orders with an emergency
170medical technician or paramedic licensed pursuant to s. 401.27,
171which relationship or orders contemplate the performance of
172medical acts, or when an osteopathic physician enters into an
173established protocol with an advanced registered nurse
174practitioner, which protocol contemplates the performance of
175medical acts identified and approved by the joint committee
176pursuant to s. 464.003(3)(c) or acts set forth in s. 464.012(3)
177and (4), the osteopathic physician shall submit notice to the
178board. The notice shall contain a statement in substantially the
179following form:
180
181     I, ...(name and professional license number of osteopathic
182physician)..., of ...(address of osteopathic physician)... have
183hereby entered into a formal supervisory relationship, standing
184orders, or an established protocol with ...(number of
185persons)... emergency medical technician(s), ...(number of
186persons)... paramedic(s), or ...(number of persons)... advanced
187registered nurse practitioner(s).
188     (b)  Notice shall be filed within 30 days of entering into
189the relationship, orders, or protocol. Notice also shall be
190provided within 30 days after the osteopathic physician has
191terminated any such relationship, orders, or protocol.
192     (2)  PROTOCOLS REQUIRING DIRECT SUPERVISION.--All protocols
193relating to electrolysis or electrology using laser or
194light-based hair removal or reduction by persons other than
195osteopathic physicians licensed under this chapter or physicians
196licensed under chapter 458 shall require the person performing
197such service to be appropriately trained and work only under the
198direct supervision and responsibility of an osteopathic
199physician licensed under this chapter or a physician licensed
200under chapter 458.
201     (3)  SUPERVISORY RELATIONSHIPS IN MEDICAL OFFICE
202SETTINGS.--An osteopathic physician who supervises an advanced
203registered nurse practitioner or physician assistant at a
204medical office other than the osteopathic physician's primary
205practice location, where the advanced registered nurse
206practitioner or physician assistant is not under the onsite
207supervision of a supervising osteopathic physician, shall comply
208with the standards set forth in this subsection. For the purpose
209of this subsection, an osteopathic physician's "primary practice
210location" means the address reflected on the osteopathic
211physician's profile published under s. 456.041.
212     (a)  An osteopathic physician who is engaged in providing
213primary health care services may not supervise more than four
214offices in addition to the osteopathic physician's primary
215practice location. For the purpose of this subsection, "primary
216health care" means health care services that are commonly
217provided to patients without referral from another practitioner,
218including obstetrical and gynecological services, and excludes
219practices providing primarily dermatologic and skin care
220services, which include aesthetic skin care services.
221     (b)  An osteopathic physician who is engaged in providing
222specialty health care services may not supervise more than two
223offices in addition to the osteopathic physician's primary
224practice location. For the purpose of this subsection,
225"specialty health care" means health care services that are
226commonly provided to patients with a referral from another
227practitioner and excludes practices providing primarily
228dermatologic and skin care services, which include aesthetic
229skin care services.
230     (c)  An osteopathic physician who supervises an advanced
231registered nurse practitioner or physician assistant at a
232medical office other than the osteopathic physician's primary
233practice location, where the advanced registered nurse
234practitioner or physician assistant is not under the onsite
235supervision of a supervising osteopathic physician and the
236services offered at the office are primarily dermatologic or
237skin care services, which include aesthetic skin care services
238other than plastic surgery, shall comply with the standards
239listed in subparagraphs 1.-4. Notwithstanding s.
240459.022(4)(e)8., an osteopathic physician supervising a
241physician assistant under this paragraph may not be required to
242review and cosign charts or medical records prepared by the
243physician assistant.
244     1.  The osteopathic physician shall submit to the board the
245addresses of all offices where he or she is supervising or has a
246protocol with an advanced registered nurse practitioner or a
247physician's assistant that are not the osteopathic physician
248primary practice location.
249     2.  The osteopathic physician shall be board certified or
250board eligible in dermatology or plastic surgery as recognized
251by the board under s. 459.0152.
252     3.  All offices in which the osteopathic physician is
253supervising an advanced registered nurse practitioner or a
254physician assistant that are not the osteopathic physician's
255primary place of practice shall be within 25 miles of the
256osteopathic physician's primary place of practice or in a county
257that is contiguous to the county of the osteopathic physician's
258primary place of practice. However, the distance between any of
259the offices may not exceed 75 miles.
260     4.  The osteopathic physician may supervise only one office
261other than the osteopathic physician's primary place of practice
262except that until July 1, 2011, the osteopathic physician may
263supervise up to two medical offices other than the osteopathic
264physician's primary place of practice if the addresses of the
265offices are submitted to the board prior to July 1, 2006.
266Effective July 1, 2011, the osteopathic physician may supervise
267only one office other than the osteopathic physician's primary
268place of practice, regardless of when the addresses of the
269offices were submitted to the board.
270     (d)  An osteopathic physician who supervises an office in
271addition to the osteopathic physician's primary practice
272location shall conspicuously post in each of the osteopathic
273physician's offices a current schedule of the regular hours that
274the osteopathic physician is present in that office and the
275hours that the office is open when the osteopathic physician is
276not present.
277     (e)  This subsection shall not apply to health care
278services provided in facilities licensed under chapter 395 or in
279conjunction with a college of medicine, college of nursing,
280accredited graduate medical program, or nursing education
281program; offices in which the only service being performed is
282hair removal by an advanced registered nurse practitioner or
283physician assistant; not-for-profit, family planning clinics
284that are not licensed pursuant to chapter 390; rural and
285federally qualified health centers; health care services
286provided in a nursing home licensed under part II of chapter
287400, an assisted living facility licensed under part III of
288chapter 400, a continuing care facility licensed under chapter
289651, or a retirement community consisting of independent living
290units and a licensed nursing home or assisted living facility;
291anesthesia services provided in accordance with law; health care
292services provided in a designated rural health clinic; health
293care services provided to persons enrolled in a program designed
294to maintain elderly persons and persons with disabilities in a
295home or community-based setting; university primary care student
296health centers; school health clinics; or health care services
297provided in federal or state facilities.
298     (4)  REQUIREMENTS FOR NOTICE AND REVIEW.--Upon initial
299referral of a patient by another practitioner, the osteopathic
300physician receiving the referral shall ensure that the patient
301is informed of the type of license held by the osteopathic
302physician and the type of license held by any other practitioner
303who will be providing services to the patient. When scheduling
304the initial examination or consultation following the referral,
305the patient may decide to see the osteopathic physician or any
306other licensed practitioner supervised by the osteopathic
307physician and, prior to the initial examination or consultation,
308shall sign a form indicating the patient's choice of
309practitioner. The supervising osteopathic physician shall review
310the medical record of the initial examination or consultation
311and ensure that a written report on the initial examination or
312consultation is furnished to the referring practitioner within
31310 business days following the completion of the initial
314examination or consultation.
315     Section 5.  Subsection (3) of section 464.012, Florida
316Statutes, is amended to read:
317     464.012  Certification of advanced registered nurse
318practitioners; fees.--
319     (3)  An advanced registered nurse practitioner shall
320perform those functions authorized in this section within the
321framework of an established protocol that shall be filed with
322the board upon biennial license renewal and within 30 days of
323entering into a supervisory relationship with a physician or
324changes to the protocol. The board shall review the protocol to
325ensure compliance with applicable regulatory standards for
326protocols. The board shall refer to the department licensees
327submitting protocols that are not compliant with the regulatory
328standards for protocols. A practitioner currently licensed under
329chapter 458, chapter 459, or chapter 466 shall maintain
330supervision for directing the specific course of medical
331treatment. Within the established framework, an advanced
332registered nurse practitioner may:
333     (a)  Monitor and alter drug therapies.
334     (b)  Initiate appropriate therapies for certain conditions.
335     (c)  Perform additional functions as may be determined by
336rule in accordance with s. 464.003(3)(c).
337     (d)  Order diagnostic tests and physical and occupational
338therapy.
339     Section 6.  This act shall take effect July 1, 2006.


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