CS/CS/HB 247

1	A bill to be entitled
2	An act relating to nursing facilities; amending s.
3	400.141, F.S.; authorizing certain licensed nursing
4	facilities to develop a plan to provide certain training
5	for nursing assistants; providing for rules relating to
6	approval of training programs by the Agency for Health
7	Care Administration; amending s. 400.147, F.S.; redefining
8	the term "adverse incident"; deleting the requirement that
9	a nursing facility notify the agency of an adverse
10	incident; deleting notification requirements; requiring
11	that a risk manager determine if an incident was an
12	adverse incident; providing applicability of federal
13	reporting requirements to investigations of adverse
14	incidents; amending s. 400.19, F.S.; providing that the
15	most recent survey is a licensure survey under certain
16	conditions for purposes of future survey scheduling;
17	amending s. 400.195, F.S.; conforming a cross-reference;
18	amending s. 400.23, F.S.; revising provisions relating to
19	a facility's use of licensed nurses to meet certain
20	minimum staffing requirements; providing an effective
21	date.
22
23	Be It Enacted by the Legislature of the State of Florida:
24
25	Section 1.  Section 400.141, Florida Statutes, is amended
26	to read:
27	400.141  Administration and management of nursing home
28	facilities.--Every licensed facility shall comply with all
29	applicable standards and rules of the agency and shall:
30	(1)  Be under the administrative direction and charge of a
31	licensed administrator.
32	(2)  Appoint a medical director licensed pursuant to
33	chapter 458 or chapter 459. The agency may establish by rule
34	more specific criteria for the appointment of a medical
35	director.
36	(3)  Have available the regular, consultative, and
37	emergency services of physicians licensed by the state.
38	(4)  Provide for resident use of a community pharmacy as
39	specified in s. 400.022(1)(q). Any other law to the contrary
40	notwithstanding, a registered pharmacist licensed in Florida,
41	that is under contract with a facility licensed under this
42	chapter or chapter 429, shall repackage a nursing facility
43	resident's bulk prescription medication which has been packaged
44	by another pharmacist licensed in any state in the United States
45	into a unit dose system compatible with the system used by the
46	nursing facility, if the pharmacist is requested to offer such
47	service. In order to be eligible for the repackaging, a resident
48	or the resident's spouse must receive prescription medication
49	benefits provided through a former employer as part of his or
50	her retirement benefits, a qualified pension plan as specified
51	in s. 4972 of the Internal Revenue Code, a federal retirement
52	program as specified under 5 C.F.R. s. 831, or a long-term care
53	policy as defined in s. 627.9404(1). A pharmacist who correctly
54	repackages and relabels the medication and the nursing facility
55	which correctly administers such repackaged medication under the
56	provisions of this subsection shall not be held liable in any
57	civil or administrative action arising from the repackaging. In
58	order to be eligible for the repackaging, a nursing facility
59	resident for whom the medication is to be repackaged shall sign
60	an informed consent form provided by the facility which includes
61	an explanation of the repackaging process and which notifies the
62	resident of the immunities from liability provided herein. A
63	pharmacist who repackages and relabels prescription medications,
64	as authorized under this subsection, may charge a reasonable fee
65	for costs resulting from the implementation of this provision.
66	(5)  Provide for the access of the facility residents to
67	dental and other health-related services, recreational services,
68	rehabilitative services, and social work services appropriate to
69	their needs and conditions and not directly furnished by the
70	licensee. When a geriatric outpatient nurse clinic is conducted
71	in accordance with rules adopted by the agency, outpatients
72	attending such clinic shall not be counted as part of the
73	general resident population of the nursing home facility, nor
74	shall the nursing staff of the geriatric outpatient clinic be
75	counted as part of the nursing staff of the facility, until the
76	outpatient clinic load exceeds 15 a day.
77	(6)  Be allowed and encouraged by the agency to provide
78	other needed services under certain conditions. If the facility
79	has a standard licensure status, and has had no class I or class
80	II deficiencies during the past 2 years or has been awarded a
81	Gold Seal under the program established in s. 400.235, it may be
82	encouraged by the agency to provide services, including, but not
83	limited to, respite and adult day services, which enable
84	individuals to move in and out of the facility. A facility is
85	not subject to any additional licensure requirements for
86	providing these services. Respite care may be offered to persons
87	in need of short-term or temporary nursing home services.
88	Respite care must be provided in accordance with this part and
89	rules adopted by the agency. However, the agency shall, by rule,
90	adopt modified requirements for resident assessment, resident
91	care plans, resident contracts, physician orders, and other
92	provisions, as appropriate, for short-term or temporary nursing
93	home services. The agency shall allow for shared programming and
94	staff in a facility which meets minimum standards and offers
95	services pursuant to this subsection, but, if the facility is
96	cited for deficiencies in patient care, may require additional
97	staff and programs appropriate to the needs of service
98	recipients. A person who receives respite care may not be
99	counted as a resident of the facility for purposes of the
100	facility's licensed capacity unless that person receives 24-hour
101	respite care. A person receiving either respite care for 24
102	hours or longer or adult day services must be included when
103	calculating minimum staffing for the facility. Any costs and
104	revenues generated by a nursing home facility from
105	nonresidential programs or services shall be excluded from the
106	calculations of Medicaid per diems for nursing home
107	institutional care reimbursement.
108	(7)  If the facility has a standard license or is a Gold
109	Seal facility, exceeds the minimum required hours of licensed
110	nursing and certified nursing assistant direct care per resident
111	per day, and is part of a continuing care facility licensed
112	under chapter 651 or a retirement community that offers other
113	services pursuant to part III of this chapter or part I or part
114	III of chapter 429 on a single campus, be allowed to share
115	programming and staff. At the time of inspection and in the
116	semiannual report required pursuant to subsection (15), a
117	continuing care facility or retirement community that uses this
118	option must demonstrate through staffing records that minimum
119	staffing requirements for the facility were met. Licensed nurses
120	and certified nursing assistants who work in the nursing home
121	facility may be used to provide services elsewhere on campus if
122	the facility exceeds the minimum number of direct care hours
123	required per resident per day and the total number of residents
124	receiving direct care services from a licensed nurse or a
125	certified nursing assistant does not cause the facility to
126	violate the staffing ratios required under s. 400.23(3)(a).
127	Compliance with the minimum staffing ratios shall be based on
128	total number of residents receiving direct care services,
129	regardless of where they reside on campus. If the facility
130	receives a conditional license, it may not share staff until the
131	conditional license status ends. This subsection does not
132	restrict the agency's authority under federal or state law to
133	require additional staff if a facility is cited for deficiencies
134	in care which are caused by an insufficient number of certified
135	nursing assistants or licensed nurses. The agency may adopt
136	rules for the documentation necessary to determine compliance
137	with this provision.
138	(8)  Maintain the facility premises and equipment and
139	conduct its operations in a safe and sanitary manner.
140	(9)  If the licensee furnishes food service, provide a
141	wholesome and nourishing diet sufficient to meet generally
142	accepted standards of proper nutrition for its residents and
143	provide such therapeutic diets as may be prescribed by attending
144	physicians. In making rules to implement this subsection, the
145	agency shall be guided by standards recommended by nationally
146	recognized professional groups and associations with knowledge
147	of dietetics.
148	(10)  Keep full records of resident admissions and
149	discharges; medical and general health status, including medical
150	records, personal and social history, and identity and address
151	of next of kin or other persons who may have responsibility for
152	the affairs of the residents; and individual resident care plans
153	including, but not limited to, prescribed services, service
154	frequency and duration, and service goals. The records shall be
155	open to inspection by the agency.
156	(11)  Keep such fiscal records of its operations and
157	conditions as may be necessary to provide information pursuant
158	to this part.
159	(12)  Furnish copies of personnel records for employees
160	affiliated with such facility, to any other facility licensed by
161	this state requesting this information pursuant to this part.
162	Such information contained in the records may include, but is
163	not limited to, disciplinary matters and any reason for
164	termination. Any facility releasing such records pursuant to
165	this part shall be considered to be acting in good faith and may
166	not be held liable for information contained in such records,
167	absent a showing that the facility maliciously falsified such
168	records.
169	(13)  Publicly display a poster provided by the agency
170	containing the names, addresses, and telephone numbers for the
171	state's abuse hotline, the State Long-Term Care Ombudsman, the
172	Agency for Health Care Administration consumer hotline, the
173	Advocacy Center for Persons with Disabilities, the Florida
174	Statewide Advocacy Council, and the Medicaid Fraud Control Unit,
175	with a clear description of the assistance to be expected from
176	each.
177	(14)  Submit to the agency the information specified in s.
178	400.071(1)(b) for a management company within 30 days after the
179	effective date of the management agreement.
180	(15)  Submit semiannually to the agency, or more frequently
181	if requested by the agency, information regarding facility
182	staff-to-resident ratios, staff turnover, and staff stability,
183	including information regarding certified nursing assistants,
184	licensed nurses, the director of nursing, and the facility
185	administrator. For purposes of this reporting:
186	(a)  Staff-to-resident ratios must be reported in the
187	categories specified in s. 400.23(3)(a) and applicable rules.
188	The ratio must be reported as an average for the most recent
189	calendar quarter.
190	(b)  Staff turnover must be reported for the most recent
191	12-month period ending on the last workday of the most recent
192	calendar quarter prior to the date the information is submitted.
193	The turnover rate must be computed quarterly, with the annual
194	rate being the cumulative sum of the quarterly rates. The
195	turnover rate is the total number of terminations or separations
196	experienced during the quarter, excluding any employee
197	terminated during a probationary period of 3 months or less,
198	divided by the total number of staff employed at the end of the
199	period for which the rate is computed, and expressed as a
200	percentage.
201	(c)  The formula for determining staff stability is the
202	total number of employees that have been employed for more than
203	12 months, divided by the total number of employees employed at
204	the end of the most recent calendar quarter, and expressed as a
205	percentage.
206	(d)  A nursing facility that has failed to comply with
207	state minimum-staffing requirements for 2 consecutive days is
208	prohibited from accepting new admissions until the facility has
209	achieved the minimum-staffing requirements for a period of 6
210	consecutive days. For the purposes of this paragraph, any person
211	who was a resident of the facility and was absent from the
212	facility for the purpose of receiving medical care at a separate
213	location or was on a leave of absence is not considered a new
214	admission. Failure to impose such an admissions moratorium
215	constitutes a class II deficiency.
216	(e)  A nursing facility which does not have a conditional
217	license may be cited for failure to comply with the standards in
218	s. 400.23(3)(a)1.a. only if it has failed to meet those
219	standards on 2 consecutive days or if it has failed to meet at
220	least 97 percent of those standards on any one day.
221	(f)  A facility which has a conditional license must be in
222	compliance with the standards in s. 400.23(3)(a) at all times.
223
224	Nothing in this section shall limit the agency's ability to
225	impose a deficiency or take other actions if a facility does not
226	have enough staff to meet the residents' needs.
227	(16)  Report monthly the number of vacant beds in the
228	facility which are available for resident occupancy on the day
229	the information is reported.
230	(17)  Notify a licensed physician when a resident exhibits
231	signs of dementia or cognitive impairment or has a change of
232	condition in order to rule out the presence of an underlying
233	physiological condition that may be contributing to such
234	dementia or impairment. The notification must occur within 30
235	days after the acknowledgment of such signs by facility staff.
236	If an underlying condition is determined to exist, the facility
237	shall arrange, with the appropriate health care provider, the
238	necessary care and services to treat the condition.
239	(18)  If the facility implements a dining and hospitality
240	attendant program, ensure that the program is developed and
241	implemented under the supervision of the facility director of
242	nursing. A licensed nurse, licensed speech or occupational
243	therapist, or a registered dietitian must conduct training of
244	dining and hospitality attendants. A person employed by a
245	facility as a dining and hospitality attendant must perform
246	tasks under the direct supervision of a licensed nurse.
247	(19)  Report to the agency any filing for bankruptcy
248	protection by the facility or its parent corporation,
249	divestiture or spin-off of its assets, or corporate
250	reorganization within 30 days after the completion of such
251	activity.
252	(20)  Maintain general and professional liability insurance
253	coverage that is in force at all times. In lieu of general and
254	professional liability insurance coverage, a state-designated
255	teaching nursing home and its affiliated assisted living
256	facilities created under s. 430.80 may demonstrate proof of
257	financial responsibility as provided in s. 430.80(3)(h).
258	(21)  Maintain in the medical record for each resident a
259	daily chart of certified nursing assistant services provided to
260	the resident. The certified nursing assistant who is caring for
261	the resident must complete this record by the end of his or her
262	shift. This record must indicate assistance with activities of
263	daily living, assistance with eating, and assistance with
264	drinking, and must record each offering of nutrition and
265	hydration for those residents whose plan of care or assessment
266	indicates a risk for malnutrition or dehydration.
267	(22)  Before November 30 of each year, subject to the
268	availability of an adequate supply of the necessary vaccine,
269	provide for immunizations against influenza viruses to all its
270	consenting residents in accordance with the recommendations of
271	the United States Centers for Disease Control and Prevention,
272	subject to exemptions for medical contraindications and
273	religious or personal beliefs. Subject to these exemptions, any
274	consenting person who becomes a resident of the facility after
275	November 30 but before March 31 of the following year must be
276	immunized within 5 working days after becoming a resident.
277	Immunization shall not be provided to any resident who provides
278	documentation that he or she has been immunized as required by
279	this subsection. This subsection does not prohibit a resident
280	from receiving the immunization from his or her personal
281	physician if he or she so chooses. A resident who chooses to
282	receive the immunization from his or her personal physician
283	shall provide proof of immunization to the facility. The agency
284	may adopt and enforce any rules necessary to comply with or
285	implement this subsection.
286	(23)  Assess all residents for eligibility for pneumococcal
287	polysaccharide vaccination (PPV) and vaccinate residents when
288	indicated within 60 days after the effective date of this act in
289	accordance with the recommendations of the United States Centers
290	for Disease Control and Prevention, subject to exemptions for
291	medical contraindications and religious or personal beliefs.
292	Residents admitted after the effective date of this act shall be
293	assessed within 5 working days of admission and, when indicated,
294	vaccinated within 60 days in accordance with the recommendations
295	of the United States Centers for Disease Control and Prevention,
296	subject to exemptions for medical contraindications and
297	religious or personal beliefs. Immunization shall not be
298	provided to any resident who provides documentation that he or
299	she has been immunized as required by this subsection. This
300	subsection does not prohibit a resident from receiving the
301	immunization from his or her personal physician if he or she so
302	chooses. A resident who chooses to receive the immunization from
303	his or her personal physician shall provide proof of
304	immunization to the facility. The agency may adopt and enforce
305	any rules necessary to comply with or implement this subsection.
306	(24)  Annually encourage and promote to its employees the
307	benefits associated with immunizations against influenza viruses
308	in accordance with the recommendations of the United States
309	Centers for Disease Control and Prevention. The agency may adopt
310	and enforce any rules necessary to comply with or implement this
311	subsection.
312
313	Facilities having a standard license that have been awarded a
314	Gold Seal under the program established in s. 400.235 may
315	develop a plan to provide certified nursing assistant training
316	as prescribed by federal regulations and state rules and may
317	apply to the agency for approval of their program. The agency
318	may adopt rules relating to the approval, suspension, or
319	termination of a certified nursing assistant training program.
320	Section 2.  Subsections (5) through (15) of section
321	400.147, Florida Statutes, are amended to read:
322	400.147  Internal risk management and quality assurance
323	program.--
324	(5)  For purposes of reporting to the agency under this
325	section, the term "adverse incident" means:
326	(a)  An event over which facility personnel could exercise
327	control and which is associated in whole or in part with the
328	facility's intervention, rather than the condition for which
329	such intervention occurred, and which results in one of the
330	following:
331	1.  Death;
332	2.  Brain or spinal damage;
333	3.  Permanent disfigurement;
334	4.  Fracture or dislocation of bones or joints;
335	5.  A limitation of neurological, physical, or sensory
336	function;
337	6.  Any condition that required medical attention to which
338	the resident has not given his or her informed consent,
339	including failure to honor advanced directives; or
340	7.  Any condition that required the transfer of the
341	resident, within or outside the facility, to a unit providing a
342	more acute level of care due to the adverse incident, rather
343	than the resident's condition prior to the adverse incident;
344	(b)  Abuse, neglect, or exploitation as defined in s.
345	415.102;
346	(c)  Abuse, neglect and harm as defined in s. 39.01;
347	(d)  Resident elopement; or
348	(e)  An event that is reported to a law enforcement agency
349	regarding a resident, other than for transportation.
350	(6)  The internal risk manager of each licensed facility
351	shall:
352	(a)  Investigate every allegation of sexual misconduct
353	which is made against a member of the facility's personnel who
354	has direct patient contact when the allegation is that the
355	sexual misconduct occurred at the facility or at the grounds of
356	the facility;
357	(b)  Report every allegation of sexual misconduct to the
358	administrator of the licensed facility; and
359	(c)  Notify the resident representative or guardian of the
360	victim that an allegation of sexual misconduct has been made and
361	that an investigation is being conducted.
362	(7)(a)  The facility shall initiate an investigation and
363	shall notify the agency within 1 business day after the risk
364	manager or his or her designee has received a report pursuant to
365	paragraph (1)(d). The notification must be made in writing and
366	be provided electronically, by facsimile device or overnight
367	mail delivery. The notification must include information
368	regarding the identity of the affected resident, the type of
369	adverse incident, the initiation of an investigation by the
370	facility, and whether the events causing or resulting in the
371	adverse incident represent a potential risk to any other
372	resident. The notification is confidential as provided by law
373	and is not discoverable or admissible in any civil or
374	administrative action, except in disciplinary proceedings by the
375	agency or the appropriate regulatory board. The agency may
376	investigate, as it deems appropriate, any such incident and
377	prescribe measures that must or may be taken in response to the
378	incident. The agency shall review each incident and determine
379	whether it potentially involved conduct by the health care
380	professional who is subject to disciplinary action, in which
381	case the provisions of s. 456.073 shall apply.
382	(b)(8)(a)  Each facility shall complete the investigation
383	and submit an adverse incident report to the agency for each
384	adverse incident within 15 calendar days after its occurrence.
385	If, after a complete investigation, the risk manager determines
386	that the incident was not an adverse incident as defined in
387	subsection (5), the facility shall include this information in
388	the report. The agency shall develop a form for reporting this
389	information.
390	(c)(b)  The information reported to the agency pursuant to
391	paragraph (b) (a) which relates to persons licensed under
392	chapter 458, chapter 459, chapter 461, or chapter 466 shall be
393	reviewed by the agency. The agency shall determine whether any
394	of the incidents potentially involved conduct by a health care
395	professional who is subject to disciplinary action, in which
396	case the provisions of s. 456.073 shall apply.
397	(d)(c)  The report submitted to the agency must also
398	contain the name of the risk manager of the facility.
399	(e)(d)  The adverse incident report is confidential as
400	provided by law and is not discoverable or admissible in any
401	civil or administrative action, except in disciplinary
402	proceedings by the agency or the appropriate regulatory board.
403	(f)  Nothing in this subsection shall affect any federal
404	reporting requirements.
405	(8)(9)  By the 10th of each month, each facility subject to
406	this section shall report any notice received pursuant to s.
407	400.0233(2) and each initial complaint that was filed with the
408	clerk of the court and served on the facility during the
409	previous month by a resident or a resident's family member,
410	guardian, conservator, or personal legal representative. The
411	report must include the name of the resident, the resident's
412	date of birth and social security number, the Medicaid
413	identification number for Medicaid-eligible persons, the date or
414	dates of the incident leading to the claim or dates of
415	residency, if applicable, and the type of injury or violation of
416	rights alleged to have occurred. Each facility shall also submit
417	a copy of the notices received pursuant to s. 400.0233(2) and
418	complaints filed with the clerk of the court. This report is
419	confidential as provided by law and is not discoverable or
420	admissible in any civil or administrative action, except in such
421	actions brought by the agency to enforce the provisions of this
422	part.
423	(9)(10)  The agency shall review, as part of its licensure
424	inspection process, the internal risk management and quality
425	assurance program at each facility regulated by this section to
426	determine whether the program meets standards established in
427	statutory laws and rules, is being conducted in a manner
428	designed to reduce adverse incidents, and is appropriately
429	reporting incidents as required by this section.
430	(10)(11)  There is no monetary liability on the part of,
431	and a cause of action for damages may not arise against, any
432	risk manager for the implementation and oversight of the
433	internal risk management and quality assurance program in a
434	facility licensed under this part as required by this section,
435	or for any act or proceeding undertaken or performed within the
436	scope of the functions of such internal risk management and
437	quality assurance program if the risk manager acts without
438	intentional fraud.
439	(11)(12)  If the agency, through its receipt of the adverse
440	incident reports prescribed in subsection (7), or through any
441	investigation, has a reasonable belief that conduct by a staff
442	member or employee of a facility is grounds for disciplinary
443	action by the appropriate regulatory board, the agency shall
444	report this fact to the regulatory board.
445	(12)(13)  The agency may adopt rules to administer this
446	section.
447	(13)(14)  The agency shall annually submit to the
448	Legislature a report on nursing home adverse incidents. The
449	report must include the following information arranged by
450	county:
451	(a)  The total number of adverse incidents.
452	(b)  A listing, by category, of the types of adverse
453	incidents, the number of incidents occurring within each
454	category, and the type of staff involved.
455	(c)  A listing, by category, of the types of injury caused
456	and the number of injuries occurring within each category.
457	(d)  Types of liability claims filed based on an adverse
458	incident or reportable injury.
459	(e)  Disciplinary action taken against staff, categorized
460	by type of staff involved.
461	(14)(15)  Information gathered by a credentialing
462	organization under a quality assurance program is not
463	discoverable from the credentialing organization. This
464	subsection does not limit discovery of, access to, or use of
465	facility records, including those records from which the
466	credentialing organization gathered its information.
467	Section 3.  Subsection (3) of section 400.19, Florida
468	Statutes, is amended to read:
469	400.19  Right of entry and inspection.--
470	(3)  The agency shall every 15 months conduct at least one
471	unannounced inspection to determine compliance by the licensee
472	with statutes, and with rules adopted promulgated under the
473	provisions of those statutes, governing minimum standards of
474	construction, quality and adequacy of care, and rights of
475	residents. The survey shall be conducted every 6 months for the
476	next 2-year period if the facility has been cited for a class I
477	deficiency, has been cited for two or more class II deficiencies
478	arising from separate surveys or investigations within a 60-day
479	period, or has had three or more substantiated complaints within
480	a 6-month period, each resulting in at least one class I or
481	class II deficiency. In addition to any other fees or fines in
482	this part, the agency shall assess a fine for each facility that
483	is subject to the 6-month survey cycle. The fine for the 2-year
484	period shall be $6,000, one-half to be paid at the completion of
485	each survey. The agency may adjust this fine by the change in
486	the Consumer Price Index, based on the 12 months immediately
487	preceding the increase, to cover the cost of the additional
488	surveys. If such deficiencies are overturned as the result of
489	administrative action but additional surveys have already been
490	conducted pursuant to this section, the most recent survey shall
491	be considered a licensure survey for purposes of scheduling
492	future surveys. The agency shall verify through subsequent
493	inspection that any deficiency identified during inspection is
494	corrected. However, the agency may verify the correction of a
495	class III or class IV deficiency unrelated to resident rights or
496	resident care without reinspecting the facility if adequate
497	written documentation has been received from the facility, which
498	provides assurance that the deficiency has been corrected. The
499	giving or causing to be given of advance notice of such
500	unannounced inspections by an employee of the agency to any
501	unauthorized person shall constitute cause for suspension of not
502	fewer than 5 working days according to the provisions of chapter
503	110.
504	Section 4.  Paragraph (d) of subsection (1) of section
505	400.195, Florida Statutes, is amended to read:
506	400.195  Agency reporting requirements.--
507	(1)  For the period beginning June 30, 2001, and ending
508	June 30, 2005, the Agency for Health Care Administration shall
509	provide a report to the Governor, the President of the Senate,
510	and the Speaker of the House of Representatives with respect to
511	nursing homes. The first report shall be submitted no later than
512	December 30, 2002, and subsequent reports shall be submitted
513	every 6 months thereafter. The report shall identify facilities
514	based on their ownership characteristics, size, business
515	structure, for-profit or not-for-profit status, and any other
516	characteristics the agency determines useful in analyzing the
517	varied segments of the nursing home industry and shall report:
518	(d)  Information regarding deficiencies cited, including
519	information used to develop the Nursing Home Guide WATCH LIST
520	pursuant to s. 400.191, and applicable rules, a summary of data
521	generated on nursing homes by Centers for Medicare and Medicaid
522	Services Nursing Home Quality Information Project, and
523	information collected pursuant to s. 400.147(8) s. 400.147(9),
524	relating to litigation.
525	Section 5.  Paragraph (a) of subsection (3) of section
526	400.23, Florida Statutes, is amended to read:
527	400.23  Rules; evaluation and deficiencies; licensure
528	status.--
529	(3)(a)1.  The agency shall adopt rules providing minimum
530	staffing requirements for nursing homes. These requirements
531	shall include, for each nursing home facility:
532	a.  A minimum certified nursing assistant staffing of 2.6
533	hours of direct care per resident per day beginning January 1,
534	2003, and increasing to 2.7 hours of direct care per resident
535	per day beginning January 1, 2007. Beginning January 1, 2002, a
536	no facility may not shall staff below one certified nursing
537	assistant per 20 residents, and must provide a minimum licensed
538	nursing staffing of 1.0 hour of direct care per resident per day
539	but never below one licensed nurse per 40 residents.
540	b.  Beginning January 1, 2007, a minimum weekly average
541	certified nursing assistant staffing of 2.9 hours of direct care
542	per resident per day. For the purpose of this sub-subparagraph,
543	a week is defined as Sunday through Saturday.
544	2.  Nursing assistants employed under s. 400.211(2) may be
545	included in computing the staffing ratio for certified nursing
546	assistants only if their job responsibilities include only
547	nursing-assistant-related duties.
548	3.  Each nursing home must document compliance with
549	staffing standards as required under this paragraph and post
550	daily the names of staff on duty for the benefit of facility
551	residents and the public.
552	4.  The agency shall recognize the use of licensed nurses
553	for compliance with minimum staffing requirements for certified
554	nursing assistants, provided that the facility otherwise meets
555	the minimum staffing requirements for licensed nurses and that
556	the licensed nurses are performing the duties of a certified
557	nursing assistant. Unless otherwise approved by the agency,
558	Licensed nurses counted toward the minimum staffing requirements
559	for certified nursing assistants must exclusively perform the
560	duties of a certified nursing assistant for the entire shift and
561	not also be counted toward the minimum staffing requirements for
562	licensed nurses. If the agency approved a facility's request to
563	use a licensed nurse to perform both licensed nursing and
564	certified nursing assistant duties, The facility must allocate
565	the amount of staff time specifically spent on certified nursing
566	assistant duties for the purpose of documenting compliance with
567	minimum staffing requirements for certified and licensed nursing
568	staff. In no event may the hours of a licensed nurse with dual
569	job responsibilities be counted twice.
570	Section 6.  This act shall take effect July 1, 2008.

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