HB 851

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

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